|
POLYSOMNOMON W C/BPAP<6HR(T
|
Facility
|
OP
|
$5,869.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
740T0004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$940.05 |
| Max. Negotiated Rate |
$5,634.24 |
| Rate for Payer: Aetna Commercial |
$4,519.13
|
| Rate for Payer: Anthem Medicaid |
$2,018.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$940.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,577.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,316.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,269.07
|
| Rate for Payer: Cash Price |
$2,934.50
|
| Rate for Payer: Cash Price |
$2,934.50
|
| Rate for Payer: Cigna Commercial |
$4,871.27
|
| Rate for Payer: First Health Commercial |
$5,575.55
|
| Rate for Payer: Humana Commercial |
$4,988.65
|
| Rate for Payer: Humana KY Medicaid |
$2,018.35
|
| Rate for Payer: Humana Medicare Advantage |
$940.05
|
| Rate for Payer: Kentucky WC Medicaid |
$2,038.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,812.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,331.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,128.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,058.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,164.72
|
| Rate for Payer: Ohio Health Group HMO |
$4,401.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,695.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,106.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,049.61
|
| Rate for Payer: PHCS Commercial |
$5,634.24
|
| Rate for Payer: United Healthcare All Payer |
$5,164.72
|
|
|
POLYSOMNOMON W C/BPAP<6HR(T
|
Facility
|
IP
|
$5,869.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
740T0004
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$1,760.70 |
| Max. Negotiated Rate |
$5,634.24 |
| Rate for Payer: Aetna Commercial |
$4,519.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,577.82
|
| Rate for Payer: Cash Price |
$2,934.50
|
| Rate for Payer: Cigna Commercial |
$4,871.27
|
| Rate for Payer: First Health Commercial |
$5,575.55
|
| Rate for Payer: Humana Commercial |
$4,988.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,812.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,331.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,760.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,164.72
|
| Rate for Payer: Ohio Health Group HMO |
$4,401.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,695.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,106.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,049.61
|
| Rate for Payer: PHCS Commercial |
$5,634.24
|
| Rate for Payer: United Healthcare All Payer |
$5,164.72
|
|
|
POLYSPORIN BACITR/POLYMYX 15GM
|
Facility
|
OP
|
$0.38
|
|
|
Service Code
|
NDC 81079888
|
| Hospital Charge Code |
25003360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.29
|
| Rate for Payer: Anthem Medicaid |
$0.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna Commercial |
$0.32
|
| Rate for Payer: First Health Commercial |
$0.36
|
| Rate for Payer: Humana Commercial |
$0.32
|
| Rate for Payer: Humana KY Medicaid |
$0.13
|
| Rate for Payer: Kentucky WC Medicaid |
$0.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.33
|
| Rate for Payer: Ohio Health Group HMO |
$0.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.26
|
| Rate for Payer: PHCS Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Payer |
$0.33
|
|
|
POLYSPORIN BACITR/POLYMYX 15GM
|
Facility
|
IP
|
$0.38
|
|
|
Service Code
|
NDC 81079888
|
| Hospital Charge Code |
25003360
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna Commercial |
$0.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna Commercial |
$0.32
|
| Rate for Payer: First Health Commercial |
$0.36
|
| Rate for Payer: Humana Commercial |
$0.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.33
|
| Rate for Payer: Ohio Health Group HMO |
$0.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.26
|
| Rate for Payer: PHCS Commercial |
$0.36
|
| Rate for Payer: United Healthcare All Payer |
$0.33
|
|
|
POLYSPORIN EYE OINT
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
NDC 24208055555
|
| Hospital Charge Code |
25001198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.54
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cigna Commercial |
$2.71
|
| Rate for Payer: First Health Commercial |
$3.10
|
| Rate for Payer: Humana Commercial |
$2.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.87
|
| Rate for Payer: Ohio Health Group HMO |
$2.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.25
|
| Rate for Payer: PHCS Commercial |
$3.13
|
| Rate for Payer: United Healthcare All Payer |
$2.87
|
|
|
POLYSPORIN EYE OINT
|
Facility
|
OP
|
$3.26
|
|
|
Service Code
|
NDC 24208055555
|
| Hospital Charge Code |
25001198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.51
|
| Rate for Payer: Anthem Medicaid |
$1.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.54
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cigna Commercial |
$2.71
|
| Rate for Payer: First Health Commercial |
$3.10
|
| Rate for Payer: Humana Commercial |
$2.77
|
| Rate for Payer: Humana KY Medicaid |
$1.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.87
|
| Rate for Payer: Ohio Health Group HMO |
$2.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.25
|
| Rate for Payer: PHCS Commercial |
$3.13
|
| Rate for Payer: United Healthcare All Payer |
$2.87
|
|
|
POLYSPORIN OINT.PACKET
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 12547023813
|
| Hospital Charge Code |
25003361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.19
|
| Rate for Payer: First Health Commercial |
$0.22
|
| Rate for Payer: Humana Commercial |
$0.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.20
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.16
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
POLYSPORIN OINT.PACKET
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 12547023813
|
| Hospital Charge Code |
25003361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna Commercial |
$0.18
|
| Rate for Payer: Anthem Medicaid |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna Commercial |
$0.19
|
| Rate for Payer: First Health Commercial |
$0.22
|
| Rate for Payer: Humana Commercial |
$0.20
|
| Rate for Payer: Humana KY Medicaid |
$0.08
|
| Rate for Payer: Kentucky WC Medicaid |
$0.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.20
|
| Rate for Payer: Ohio Health Group HMO |
$0.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.16
|
| Rate for Payer: PHCS Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Payer |
$0.20
|
|
|
POLYTRIM (TRIMETH/POLYMYX 10ML
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
25001200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna Commercial |
$0.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna Commercial |
$0.36
|
| Rate for Payer: First Health Commercial |
$0.41
|
| Rate for Payer: Humana Commercial |
$0.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.38
|
| Rate for Payer: Ohio Health Group HMO |
$0.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.30
|
| Rate for Payer: PHCS Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Payer |
$0.38
|
|
|
POLYTRIM (TRIMETH/POLYMYX 10ML
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 24208031510
|
| Hospital Charge Code |
25001200
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna Commercial |
$0.33
|
| Rate for Payer: Anthem Medicaid |
$0.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.34
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna Commercial |
$0.36
|
| Rate for Payer: First Health Commercial |
$0.41
|
| Rate for Payer: Humana Commercial |
$0.37
|
| Rate for Payer: Humana KY Medicaid |
$0.15
|
| Rate for Payer: Kentucky WC Medicaid |
$0.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.38
|
| Rate for Payer: Ohio Health Group HMO |
$0.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.30
|
| Rate for Payer: PHCS Commercial |
$0.41
|
| Rate for Payer: United Healthcare All Payer |
$0.38
|
|
|
PORT DRAW
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
HCPCS 36591
|
| Hospital Charge Code |
76101492
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem Medicaid |
$119.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$119.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Humana KY Medicaid |
$119.10
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$120.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$121.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.58
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
|
PORT DRAW
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 36591
|
| Hospital Charge Code |
76101492
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$146.15
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.58
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
|
PORT FLUSH
|
Facility
|
IP
|
$247.00
|
|
|
Service Code
|
HCPCS 96523
|
| Hospital Charge Code |
45000312
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$74.10 |
| Max. Negotiated Rate |
$237.12 |
| Rate for Payer: Aetna Commercial |
$190.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.66
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cigna Commercial |
$205.01
|
| Rate for Payer: First Health Commercial |
$234.65
|
| Rate for Payer: Humana Commercial |
$209.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$202.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$182.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$217.36
|
| Rate for Payer: Ohio Health Group HMO |
$185.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$197.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.43
|
| Rate for Payer: PHCS Commercial |
$237.12
|
| Rate for Payer: United Healthcare All Payer |
$217.36
|
|
|
PORT FLUSH
|
Facility
|
OP
|
$247.00
|
|
|
Service Code
|
HCPCS 96523
|
| Hospital Charge Code |
45000312
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$190.19
|
| Rate for Payer: Anthem Medicaid |
$84.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$192.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cash Price |
$123.50
|
| Rate for Payer: Cigna Commercial |
$205.01
|
| Rate for Payer: First Health Commercial |
$234.65
|
| Rate for Payer: Humana Commercial |
$209.95
|
| Rate for Payer: Humana KY Medicaid |
$84.94
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$85.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$202.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$182.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$86.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$217.36
|
| Rate for Payer: Ohio Health Group HMO |
$185.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$197.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$214.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$170.43
|
| Rate for Payer: PHCS Commercial |
$237.12
|
| Rate for Payer: United Healthcare All Payer |
$217.36
|
|
|
PORT IMAGE ADDITIONAL SITE
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
HCPCS 77417
|
| Hospital Charge Code |
33300027
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$86.10 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$249.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.03
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
PORT IMAGE ADDITIONAL SITE
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
HCPCS 77417
|
| Hospital Charge Code |
33300027
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$86.10 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem Medicaid |
$98.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Humana KY Medicaid |
$98.70
|
| Rate for Payer: Kentucky WC Medicaid |
$99.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$229.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$249.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.03
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
PORT POWERLINE DUAL LUMEN 5FR
|
Facility
|
IP
|
$3,319.06
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$995.72 |
| Max. Negotiated Rate |
$3,186.30 |
| Rate for Payer: Aetna Commercial |
$2,555.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,588.87
|
| Rate for Payer: Cash Price |
$1,659.53
|
| Rate for Payer: Cigna Commercial |
$2,754.82
|
| Rate for Payer: First Health Commercial |
$3,153.11
|
| Rate for Payer: Humana Commercial |
$2,821.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,721.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,449.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$995.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,920.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,489.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,655.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,887.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,290.15
|
| Rate for Payer: PHCS Commercial |
$3,186.30
|
| Rate for Payer: United Healthcare All Payer |
$2,920.77
|
|
|
PORT POWERLINE DUAL LUMEN 5FR
|
Facility
|
OP
|
$3,319.06
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$995.72 |
| Max. Negotiated Rate |
$3,186.30 |
| Rate for Payer: Aetna Commercial |
$2,555.68
|
| Rate for Payer: Anthem Medicaid |
$1,141.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,588.87
|
| Rate for Payer: Cash Price |
$1,659.53
|
| Rate for Payer: Cigna Commercial |
$2,754.82
|
| Rate for Payer: First Health Commercial |
$3,153.11
|
| Rate for Payer: Humana Commercial |
$2,821.20
|
| Rate for Payer: Humana KY Medicaid |
$1,141.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,153.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,721.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,449.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$995.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,164.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,920.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,489.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,655.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,887.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,290.15
|
| Rate for Payer: PHCS Commercial |
$3,186.30
|
| Rate for Payer: United Healthcare All Payer |
$2,920.77
|
|
|
PORT POWERLINE SINGLE LUMEN 5F
|
Facility
|
IP
|
$3,047.38
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$914.21 |
| Max. Negotiated Rate |
$2,925.48 |
| Rate for Payer: Aetna Commercial |
$2,346.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,376.96
|
| Rate for Payer: Cash Price |
$1,523.69
|
| Rate for Payer: Cigna Commercial |
$2,529.33
|
| Rate for Payer: First Health Commercial |
$2,895.01
|
| Rate for Payer: Humana Commercial |
$2,590.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,498.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,248.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$914.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,681.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,285.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,437.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,651.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,102.69
|
| Rate for Payer: PHCS Commercial |
$2,925.48
|
| Rate for Payer: United Healthcare All Payer |
$2,681.69
|
|
|
PORT POWERLINE SINGLE LUMEN 5F
|
Facility
|
OP
|
$3,047.38
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$914.21 |
| Max. Negotiated Rate |
$2,925.48 |
| Rate for Payer: Aetna Commercial |
$2,346.48
|
| Rate for Payer: Anthem Medicaid |
$1,047.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,376.96
|
| Rate for Payer: Cash Price |
$1,523.69
|
| Rate for Payer: Cigna Commercial |
$2,529.33
|
| Rate for Payer: First Health Commercial |
$2,895.01
|
| Rate for Payer: Humana Commercial |
$2,590.27
|
| Rate for Payer: Humana KY Medicaid |
$1,047.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,058.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,498.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,248.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$914.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,069.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,681.69
|
| Rate for Payer: Ohio Health Group HMO |
$2,285.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,437.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,651.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,102.69
|
| Rate for Payer: PHCS Commercial |
$2,925.48
|
| Rate for Payer: United Healthcare All Payer |
$2,681.69
|
|
|
POSITIONAL NYSTAGMUS TEST
|
Facility
|
IP
|
$263.00
|
|
|
Service Code
|
HCPCS 92542
|
| Hospital Charge Code |
47000006
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$252.48 |
| Rate for Payer: Aetna Commercial |
$202.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$205.14
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cigna Commercial |
$218.29
|
| Rate for Payer: First Health Commercial |
$249.85
|
| Rate for Payer: Humana Commercial |
$223.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$215.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$194.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$231.44
|
| Rate for Payer: Ohio Health Group HMO |
$197.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$210.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$181.47
|
| Rate for Payer: PHCS Commercial |
$252.48
|
| Rate for Payer: United Healthcare All Payer |
$231.44
|
|
|
POSITIONAL NYSTAGMUS TEST
|
Facility
|
OP
|
$263.00
|
|
|
Service Code
|
HCPCS 92542
|
| Hospital Charge Code |
47000006
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$90.45 |
| Max. Negotiated Rate |
$252.48 |
| Rate for Payer: Aetna Commercial |
$202.51
|
| Rate for Payer: Anthem Medicaid |
$90.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$205.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cigna Commercial |
$218.29
|
| Rate for Payer: First Health Commercial |
$249.85
|
| Rate for Payer: Humana Commercial |
$223.55
|
| Rate for Payer: Humana KY Medicaid |
$90.45
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$91.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$215.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$194.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$92.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$231.44
|
| Rate for Payer: Ohio Health Group HMO |
$197.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$210.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$181.47
|
| Rate for Payer: PHCS Commercial |
$252.48
|
| Rate for Payer: United Healthcare All Payer |
$231.44
|
|
|
POSITIONAL NYSTAGMUS TEST
|
Professional
|
Both
|
$263.00
|
|
|
Service Code
|
HCPCS 92542
|
| Hospital Charge Code |
47000006
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$157.80 |
| Rate for Payer: Aetna Commercial |
$89.69
|
| Rate for Payer: Ambetter Exchange |
$26.80
|
| Rate for Payer: Anthem Medicaid |
$27.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.16
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cigna Commercial |
$85.55
|
| Rate for Payer: Healthspan PPO |
$73.40
|
| Rate for Payer: Humana Medicaid |
$27.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.30
|
| Rate for Payer: Molina Healthcare Passport |
$27.75
|
| Rate for Payer: Multiplan PHCS |
$157.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.84
|
| Rate for Payer: UHCCP Medicaid |
$92.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.80
|
|
|
POSITIONAL NYSTAGMUS TEST(P
|
Professional
|
Both
|
$85.00
|
|
|
Service Code
|
HCPCS 92542
|
| Hospital Charge Code |
470P0006
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$89.69 |
| Rate for Payer: Aetna Commercial |
$89.69
|
| Rate for Payer: Ambetter Exchange |
$26.80
|
| Rate for Payer: Anthem Medicaid |
$27.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.16
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$85.55
|
| Rate for Payer: Healthspan PPO |
$73.40
|
| Rate for Payer: Humana Medicaid |
$27.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$19.82
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.30
|
| Rate for Payer: Molina Healthcare Passport |
$27.75
|
| Rate for Payer: Multiplan PHCS |
$51.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.84
|
| Rate for Payer: UHCCP Medicaid |
$29.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.80
|
|
|
POSITIONAL NYSTAGMUS TEST(T
|
Facility
|
IP
|
$178.00
|
|
|
Service Code
|
HCPCS 92542
|
| Hospital Charge Code |
470T0006
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$53.40 |
| Max. Negotiated Rate |
$170.88 |
| Rate for Payer: Aetna Commercial |
$137.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$138.84
|
| Rate for Payer: Cash Price |
$89.00
|
| Rate for Payer: Cigna Commercial |
$147.74
|
| Rate for Payer: First Health Commercial |
$169.10
|
| Rate for Payer: Humana Commercial |
$151.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$156.64
|
| Rate for Payer: Ohio Health Group HMO |
$133.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$122.82
|
| Rate for Payer: PHCS Commercial |
$170.88
|
| Rate for Payer: United Healthcare All Payer |
$156.64
|
|
