|
PRE-OP SERVICE LVRS MIN 6
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
HCPCS G0305
|
| Hospital Charge Code |
94000016
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$686.36 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem Medicaid |
$19.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Humana KY Medicaid |
$19.09
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$19.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PREPARATION H (57GM)
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 536128806
|
| Hospital Charge Code |
25004113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
PREPARATION H (57GM)
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 536128806
|
| Hospital Charge Code |
25004113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
PREPARATION OF REPORT
|
Facility
|
IP
|
$252.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
90000014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$75.73 |
| Max. Negotiated Rate |
$242.32 |
| Rate for Payer: Aetna Commercial |
$194.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.89
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cigna Commercial |
$209.51
|
| Rate for Payer: First Health Commercial |
$239.80
|
| Rate for Payer: Humana Commercial |
$214.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$222.13
|
| Rate for Payer: Ohio Health Group HMO |
$189.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.17
|
| Rate for Payer: PHCS Commercial |
$242.32
|
| Rate for Payer: United Healthcare All Payer |
$222.13
|
|
|
PREPARATION OF REPORT
|
Professional
|
Both
|
$252.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
90000014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$176.69 |
| Rate for Payer: Aetna Commercial |
$112.87
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cigna Commercial |
$104.15
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.34
|
| Rate for Payer: Multiplan PHCS |
$151.45
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$176.69
|
| Rate for Payer: UHCCP Medicaid |
$88.35
|
|
|
PREPARATION OF REPORT
|
Facility
|
OP
|
$252.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
90000014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$75.73 |
| Max. Negotiated Rate |
$242.32 |
| Rate for Payer: Aetna Commercial |
$194.36
|
| Rate for Payer: Anthem Medicaid |
$86.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.89
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cigna Commercial |
$209.51
|
| Rate for Payer: First Health Commercial |
$239.80
|
| Rate for Payer: Humana Commercial |
$214.56
|
| Rate for Payer: Humana KY Medicaid |
$86.81
|
| Rate for Payer: Kentucky WC Medicaid |
$87.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$222.13
|
| Rate for Payer: Ohio Health Group HMO |
$189.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.17
|
| Rate for Payer: PHCS Commercial |
$242.32
|
| Rate for Payer: United Healthcare All Payer |
$222.13
|
|
|
PREPARATION OF REPORT(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
900P0014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$112.87 |
| Rate for Payer: Aetna Commercial |
$112.87
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$104.15
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.34
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
|
|
PREPARATION OF REPORT(T
|
Facility
|
IP
|
$152.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
900T0014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$45.73 |
| Max. Negotiated Rate |
$146.32 |
| Rate for Payer: Aetna Commercial |
$117.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.89
|
| Rate for Payer: Cash Price |
$76.21
|
| Rate for Payer: Cigna Commercial |
$126.51
|
| Rate for Payer: First Health Commercial |
$144.80
|
| Rate for Payer: Humana Commercial |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$134.13
|
| Rate for Payer: Ohio Health Group HMO |
$114.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.17
|
| Rate for Payer: PHCS Commercial |
$146.32
|
| Rate for Payer: United Healthcare All Payer |
$134.13
|
|
|
PREPARATION OF REPORT(T
|
Facility
|
OP
|
$152.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
900T0014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$45.73 |
| Max. Negotiated Rate |
$146.32 |
| Rate for Payer: Aetna Commercial |
$117.36
|
| Rate for Payer: Anthem Medicaid |
$52.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.89
|
| Rate for Payer: Cash Price |
$76.21
|
| Rate for Payer: Cigna Commercial |
$126.51
|
| Rate for Payer: First Health Commercial |
$144.80
|
| Rate for Payer: Humana Commercial |
$129.56
|
| Rate for Payer: Humana KY Medicaid |
$52.42
|
| Rate for Payer: Kentucky WC Medicaid |
$52.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$134.13
|
| Rate for Payer: Ohio Health Group HMO |
$114.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$121.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.17
|
| Rate for Payer: PHCS Commercial |
$146.32
|
| Rate for Payer: United Healthcare All Payer |
$134.13
|
|
|
PREPARE DONOR LUNG SINGLE
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 32855
|
| Hospital Charge Code |
76101234
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
PREPARE DONOR LUNG SINGLE
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 32855
|
| Hospital Charge Code |
76101234
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.24 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Healthspan PPO |
$264.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$265.18
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
|
|
PREPARE DONOR LUNG SINGLE
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 32855
|
| Hospital Charge Code |
76101234
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
PREPARE DONOR LUNG SINGLE(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 32855
|
| Hospital Charge Code |
761P1234
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.24 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Healthspan PPO |
$264.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$265.18
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
|
|
PRE PEN 0.25ML AMPUL
|
Facility
|
IP
|
$590.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003370
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$177.12 |
| Max. Negotiated Rate |
$566.78 |
| Rate for Payer: Aetna Commercial |
$454.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$460.51
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$490.03
|
| Rate for Payer: First Health Commercial |
$560.88
|
| Rate for Payer: Humana Commercial |
$501.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$484.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$435.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$519.55
|
| Rate for Payer: Ohio Health Group HMO |
$442.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$472.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$407.38
|
| Rate for Payer: PHCS Commercial |
$566.78
|
| Rate for Payer: United Healthcare All Payer |
$519.55
|
|
|
PRE PEN 0.25ML AMPUL
|
Facility
|
OP
|
$590.40
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003370
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$177.12 |
| Max. Negotiated Rate |
$566.78 |
| Rate for Payer: Aetna Commercial |
$454.61
|
| Rate for Payer: Anthem Medicaid |
$203.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$460.51
|
| Rate for Payer: Cash Price |
$295.20
|
| Rate for Payer: Cigna Commercial |
$490.03
|
| Rate for Payer: First Health Commercial |
$560.88
|
| Rate for Payer: Humana Commercial |
$501.84
|
| Rate for Payer: Humana KY Medicaid |
$203.04
|
| Rate for Payer: Kentucky WC Medicaid |
$205.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$484.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$435.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$207.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$519.55
|
| Rate for Payer: Ohio Health Group HMO |
$442.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$472.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$407.38
|
| Rate for Payer: PHCS Commercial |
$566.78
|
| Rate for Payer: United Healthcare All Payer |
$519.55
|
|
|
PREP FECAL MICROB INSTILLATION
|
Facility
|
OP
|
$1,357.20
|
|
|
Service Code
|
HCPCS 44705
|
| Hospital Charge Code |
761T1863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$407.16 |
| Max. Negotiated Rate |
$1,302.91 |
| Rate for Payer: Aetna Commercial |
$1,045.04
|
| Rate for Payer: Anthem Medicaid |
$466.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,058.62
|
| Rate for Payer: Cash Price |
$678.60
|
| Rate for Payer: Cigna Commercial |
$1,126.48
|
| Rate for Payer: First Health Commercial |
$1,289.34
|
| Rate for Payer: Humana Commercial |
$1,153.62
|
| Rate for Payer: Humana KY Medicaid |
$466.74
|
| Rate for Payer: Kentucky WC Medicaid |
$471.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,112.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,001.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$407.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$476.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,194.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,017.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,180.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.47
|
| Rate for Payer: PHCS Commercial |
$1,302.91
|
| Rate for Payer: United Healthcare All Payer |
$1,194.34
|
|
|
PREP FECAL MICROB INSTILLATION
|
Facility
|
OP
|
$1,532.20
|
|
|
Service Code
|
HCPCS 44705
|
| Hospital Charge Code |
76101863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$459.66 |
| Max. Negotiated Rate |
$1,470.91 |
| Rate for Payer: Aetna Commercial |
$1,179.79
|
| Rate for Payer: Anthem Medicaid |
$526.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,195.12
|
| Rate for Payer: Cash Price |
$766.10
|
| Rate for Payer: Cigna Commercial |
$1,271.73
|
| Rate for Payer: First Health Commercial |
$1,455.59
|
| Rate for Payer: Humana Commercial |
$1,302.37
|
| Rate for Payer: Humana KY Medicaid |
$526.92
|
| Rate for Payer: Kentucky WC Medicaid |
$532.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,256.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,130.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$537.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,348.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,149.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,225.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,333.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,057.22
|
| Rate for Payer: PHCS Commercial |
$1,470.91
|
| Rate for Payer: United Healthcare All Payer |
$1,348.34
|
|
|
PREP FECAL MICROB INSTILLATION
|
Professional
|
Both
|
$1,532.20
|
|
|
Service Code
|
HCPCS 44705
|
| Hospital Charge Code |
76101863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,072.54 |
| Rate for Payer: Anthem Medicaid |
$89.44
|
| Rate for Payer: Cash Price |
$766.10
|
| Rate for Payer: Cash Price |
$766.10
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$89.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.23
|
| Rate for Payer: Molina Healthcare Passport |
$89.44
|
| Rate for Payer: Multiplan PHCS |
$919.32
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,072.54
|
| Rate for Payer: UHCCP Medicaid |
$536.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.33
|
|
|
PREP FECAL MICROB INSTILLATION
|
Facility
|
IP
|
$1,532.20
|
|
|
Service Code
|
HCPCS 44705
|
| Hospital Charge Code |
76101863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$459.66 |
| Max. Negotiated Rate |
$1,470.91 |
| Rate for Payer: Aetna Commercial |
$1,179.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,195.12
|
| Rate for Payer: Cash Price |
$766.10
|
| Rate for Payer: Cigna Commercial |
$1,271.73
|
| Rate for Payer: First Health Commercial |
$1,455.59
|
| Rate for Payer: Humana Commercial |
$1,302.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,256.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,130.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,348.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,149.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,225.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,333.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,057.22
|
| Rate for Payer: PHCS Commercial |
$1,470.91
|
| Rate for Payer: United Healthcare All Payer |
$1,348.34
|
|
|
PREP FECAL MICROB INSTILLATION
|
Professional
|
Both
|
$175.00
|
|
|
Service Code
|
HCPCS 44705
|
| Hospital Charge Code |
761P1863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$122.50 |
| Rate for Payer: Anthem Medicaid |
$89.44
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$89.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$101.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$91.23
|
| Rate for Payer: Molina Healthcare Passport |
$89.44
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$90.33
|
|
|
PREP FECAL MICROB INSTILLATION
|
Facility
|
IP
|
$1,357.20
|
|
|
Service Code
|
HCPCS 44705
|
| Hospital Charge Code |
761T1863
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$407.16 |
| Max. Negotiated Rate |
$1,302.91 |
| Rate for Payer: Aetna Commercial |
$1,045.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,058.62
|
| Rate for Payer: Cash Price |
$678.60
|
| Rate for Payer: Cigna Commercial |
$1,126.48
|
| Rate for Payer: First Health Commercial |
$1,289.34
|
| Rate for Payer: Humana Commercial |
$1,153.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,112.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,001.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$407.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,194.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,017.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,085.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,180.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.47
|
| Rate for Payer: PHCS Commercial |
$1,302.91
|
| Rate for Payer: United Healthcare All Payer |
$1,194.34
|
|
|
PREPIDIL (DINOPROSTON .5MG/1EA
|
Facility
|
IP
|
$965.90
|
|
|
Service Code
|
NDC 9335901
|
| Hospital Charge Code |
25001223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.77 |
| Max. Negotiated Rate |
$927.26 |
| Rate for Payer: Aetna Commercial |
$743.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$753.40
|
| Rate for Payer: Cash Price |
$482.95
|
| Rate for Payer: Cigna Commercial |
$801.70
|
| Rate for Payer: First Health Commercial |
$917.61
|
| Rate for Payer: Humana Commercial |
$821.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$792.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$712.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$289.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$849.99
|
| Rate for Payer: Ohio Health Group HMO |
$724.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$666.47
|
| Rate for Payer: PHCS Commercial |
$927.26
|
| Rate for Payer: United Healthcare All Payer |
$849.99
|
|
|
PREPIDIL (DINOPROSTON .5MG/1EA
|
Facility
|
OP
|
$965.90
|
|
|
Service Code
|
NDC 9335901
|
| Hospital Charge Code |
25001223
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.77 |
| Max. Negotiated Rate |
$927.26 |
| Rate for Payer: Aetna Commercial |
$743.74
|
| Rate for Payer: Anthem Medicaid |
$332.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$753.40
|
| Rate for Payer: Cash Price |
$482.95
|
| Rate for Payer: Cigna Commercial |
$801.70
|
| Rate for Payer: First Health Commercial |
$917.61
|
| Rate for Payer: Humana Commercial |
$821.01
|
| Rate for Payer: Humana KY Medicaid |
$332.17
|
| Rate for Payer: Kentucky WC Medicaid |
$335.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$792.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$712.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$289.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$338.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$849.99
|
| Rate for Payer: Ohio Health Group HMO |
$724.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$772.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$840.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$666.47
|
| Rate for Payer: PHCS Commercial |
$927.26
|
| Rate for Payer: United Healthcare All Payer |
$849.99
|
|
|
PREP IM ENCHANCE TOT HIP KIT
|
Facility
|
OP
|
$2,113.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$633.96 |
| Max. Negotiated Rate |
$2,028.67 |
| Rate for Payer: Aetna Commercial |
$1,627.16
|
| Rate for Payer: Anthem Medicaid |
$726.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,648.30
|
| Rate for Payer: Cash Price |
$1,056.60
|
| Rate for Payer: Cigna Commercial |
$1,753.96
|
| Rate for Payer: First Health Commercial |
$2,007.54
|
| Rate for Payer: Humana Commercial |
$1,796.22
|
| Rate for Payer: Humana KY Medicaid |
$726.73
|
| Rate for Payer: Kentucky WC Medicaid |
$734.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,732.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,559.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$741.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,859.62
|
| Rate for Payer: Ohio Health Group HMO |
$1,584.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,690.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,838.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,458.11
|
| Rate for Payer: PHCS Commercial |
$2,028.67
|
| Rate for Payer: United Healthcare All Payer |
$1,859.62
|
|
|
PREP IM ENCHANCE TOT HIP KIT
|
Facility
|
IP
|
$2,113.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$633.96 |
| Max. Negotiated Rate |
$2,028.67 |
| Rate for Payer: Aetna Commercial |
$1,627.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,648.30
|
| Rate for Payer: Cash Price |
$1,056.60
|
| Rate for Payer: Cigna Commercial |
$1,753.96
|
| Rate for Payer: First Health Commercial |
$2,007.54
|
| Rate for Payer: Humana Commercial |
$1,796.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,732.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,559.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$633.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,859.62
|
| Rate for Payer: Ohio Health Group HMO |
$1,584.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,690.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,838.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,458.11
|
| Rate for Payer: PHCS Commercial |
$2,028.67
|
| Rate for Payer: United Healthcare All Payer |
$1,859.62
|
|
