|
PROCTOSIGMOIDOSCOPY DIAGN
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS 45300
|
| Hospital Charge Code |
76101880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.99 |
| Max. Negotiated Rate |
$124.40 |
| Rate for Payer: Aetna Commercial |
$71.51
|
| Rate for Payer: Ambetter Exchange |
$45.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.22
|
| Rate for Payer: Anthem Medicaid |
$36.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$45.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.01
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$112.22
|
| Rate for Payer: Healthspan PPO |
$124.40
|
| Rate for Payer: Humana Medicaid |
$36.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$66.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$45.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.73
|
| Rate for Payer: Molina Healthcare Passport |
$36.99
|
| Rate for Payer: Multiplan PHCS |
$82.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.59
|
| Rate for Payer: UHCCP Medicaid |
$45.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$45.84
|
|
|
PROCTOSIGMOIDOSCOPY DIAGN
|
Facility
|
IP
|
$138.00
|
|
|
Service Code
|
HCPCS 45300
|
| Hospital Charge Code |
76101880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.40 |
| Max. Negotiated Rate |
$132.48 |
| Rate for Payer: Aetna Commercial |
$106.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$107.64
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$114.54
|
| Rate for Payer: First Health Commercial |
$131.10
|
| Rate for Payer: Humana Commercial |
$117.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.44
|
| Rate for Payer: Ohio Health Group HMO |
$103.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.22
|
| Rate for Payer: PHCS Commercial |
$132.48
|
| Rate for Payer: United Healthcare All Payer |
$121.44
|
|
|
PROCTOSIGMOIDOSCOPY DIAGN
|
Facility
|
OP
|
$138.00
|
|
|
Service Code
|
HCPCS 45300
|
| Hospital Charge Code |
76101880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$47.46 |
| Max. Negotiated Rate |
$1,179.36 |
| Rate for Payer: Aetna Commercial |
$106.26
|
| Rate for Payer: Anthem Medicaid |
$47.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$842.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$107.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,179.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,137.24
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$114.54
|
| Rate for Payer: First Health Commercial |
$131.10
|
| Rate for Payer: Humana Commercial |
$117.30
|
| Rate for Payer: Humana KY Medicaid |
$47.46
|
| Rate for Payer: Humana Medicare Advantage |
$842.40
|
| Rate for Payer: Kentucky WC Medicaid |
$47.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$101.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$48.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$121.44
|
| Rate for Payer: Ohio Health Group HMO |
$103.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$95.22
|
| Rate for Payer: PHCS Commercial |
$132.48
|
| Rate for Payer: United Healthcare All Payer |
$121.44
|
|
|
PROCTOSIGMOIDOSCOPY DIAGN(P
|
Professional
|
Both
|
$138.00
|
|
|
Service Code
|
HCPCS 45300
|
| Hospital Charge Code |
761P1880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$36.99 |
| Max. Negotiated Rate |
$124.40 |
| Rate for Payer: Aetna Commercial |
$71.51
|
| Rate for Payer: Ambetter Exchange |
$45.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.22
|
| Rate for Payer: Anthem Medicaid |
$36.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$45.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$55.01
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cash Price |
$69.00
|
| Rate for Payer: Cigna Commercial |
$112.22
|
| Rate for Payer: Healthspan PPO |
$124.40
|
| Rate for Payer: Humana Medicaid |
$36.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$66.10
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$45.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$37.73
|
| Rate for Payer: Molina Healthcare Passport |
$36.99
|
| Rate for Payer: Multiplan PHCS |
$82.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$59.59
|
| Rate for Payer: UHCCP Medicaid |
$45.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$45.84
|
|
|
PROCTOSIGMOIDOSCOPY FB
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 45307
|
| Hospital Charge Code |
76102611
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.24 |
| Max. Negotiated Rate |
$227.49 |
| Rate for Payer: Aetna Commercial |
$140.23
|
| Rate for Payer: Ambetter Exchange |
$95.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.24
|
| Rate for Payer: Anthem Medicaid |
$88.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$95.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$95.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.92
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$83.44
|
| Rate for Payer: Healthspan PPO |
$227.49
|
| Rate for Payer: Humana Medicaid |
$88.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.07
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$95.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$95.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.39
|
| Rate for Payer: Molina Healthcare Passport |
$88.62
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$124.50
|
| Rate for Payer: UHCCP Medicaid |
$59.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$95.77
|
|
|
PROCTOSIGMOIDOSCOPY FB
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 45307
|
| Hospital Charge Code |
76102611
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
PROCTOSIGMOIDOSCOPY FB
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 45307
|
| Hospital Charge Code |
761P2611
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.24 |
| Max. Negotiated Rate |
$227.49 |
| Rate for Payer: Aetna Commercial |
$140.23
|
| Rate for Payer: Ambetter Exchange |
$95.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.24
|
| Rate for Payer: Anthem Medicaid |
$88.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$95.77
|
| Rate for Payer: Buckeye Medicare Advantage |
$95.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$114.92
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$83.44
|
| Rate for Payer: Healthspan PPO |
$227.49
|
| Rate for Payer: Humana Medicaid |
$88.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.07
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$95.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$95.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$90.39
|
| Rate for Payer: Molina Healthcare Passport |
$88.62
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$124.50
|
| Rate for Payer: UHCCP Medicaid |
$59.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$89.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$95.77
|
|
|
PROCTOSIGMOIDOSCOPY FB
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 45307
|
| Hospital Charge Code |
76102611
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.17 |
| Max. Negotiated Rate |
$3,547.47 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem Medicaid |
$103.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,533.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,547.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,420.78
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Humana KY Medicaid |
$103.17
|
| Rate for Payer: Humana Medicare Advantage |
$2,533.91
|
| Rate for Payer: Kentucky WC Medicaid |
$104.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$1,179.36
|
|
|
Service Code
|
CPT 45300
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$842.40 |
| Max. Negotiated Rate |
$1,179.36 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$842.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,179.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,137.24
|
| Rate for Payer: Humana Medicare Advantage |
$842.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.88
|
|
|
PROCTOSIGMOIDOSCOPY - WITH DI
|
Facility
|
IP
|
$1,025.00
|
|
|
Service Code
|
HCPCS 45303
|
| Hospital Charge Code |
76101881
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$307.50 |
| Max. Negotiated Rate |
$984.00 |
| Rate for Payer: Aetna Commercial |
$789.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$799.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$850.75
|
| Rate for Payer: First Health Commercial |
$973.75
|
| Rate for Payer: Humana Commercial |
$871.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$840.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$756.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$902.00
|
| Rate for Payer: Ohio Health Group HMO |
$768.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$820.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$891.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$707.25
|
| Rate for Payer: PHCS Commercial |
$984.00
|
| Rate for Payer: United Healthcare All Payer |
$902.00
|
|
|
PROCTOSIGMOIDOSCOPY - WITH DI
|
Facility
|
OP
|
$1,025.00
|
|
|
Service Code
|
HCPCS 45303
|
| Hospital Charge Code |
76101881
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,525.23 |
| Rate for Payer: Aetna Commercial |
$789.25
|
| Rate for Payer: Anthem Medicaid |
$352.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,089.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$799.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,525.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,470.76
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$850.75
|
| Rate for Payer: First Health Commercial |
$973.75
|
| Rate for Payer: Humana Commercial |
$871.25
|
| Rate for Payer: Humana KY Medicaid |
$352.50
|
| Rate for Payer: Humana Medicare Advantage |
$1,089.45
|
| Rate for Payer: Kentucky WC Medicaid |
$356.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$840.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$756.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$359.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$902.00
|
| Rate for Payer: Ohio Health Group HMO |
$768.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$820.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$891.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$707.25
|
| Rate for Payer: PHCS Commercial |
$984.00
|
| Rate for Payer: United Healthcare All Payer |
$902.00
|
|
|
PROCTOSIGMOIDOSCOPY - WITH DI
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 45303
|
| Hospital Charge Code |
76101881
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.75 |
| Max. Negotiated Rate |
$943.54 |
| Rate for Payer: Aetna Commercial |
$121.74
|
| Rate for Payer: Ambetter Exchange |
$80.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.09
|
| Rate for Payer: Anthem Medicaid |
$34.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$80.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$80.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$96.41
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$45.19
|
| Rate for Payer: Healthspan PPO |
$943.54
|
| Rate for Payer: Humana Medicaid |
$34.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$80.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.45
|
| Rate for Payer: Molina Healthcare Passport |
$34.75
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.44
|
| Rate for Payer: UHCCP Medicaid |
$45.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$80.34
|
|
|
PROCTOSIGMOIDOSCOPY - WITH D(P
|
Professional
|
Both
|
$1,025.00
|
|
|
Service Code
|
HCPCS 45303
|
| Hospital Charge Code |
761P1881
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$34.75 |
| Max. Negotiated Rate |
$943.54 |
| Rate for Payer: Aetna Commercial |
$121.74
|
| Rate for Payer: Ambetter Exchange |
$80.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.09
|
| Rate for Payer: Anthem Medicaid |
$34.75
|
| Rate for Payer: Buckeye Individual/Medicaid |
$80.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$80.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$96.41
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cash Price |
$512.50
|
| Rate for Payer: Cigna Commercial |
$45.19
|
| Rate for Payer: Healthspan PPO |
$943.54
|
| Rate for Payer: Humana Medicaid |
$34.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.74
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$80.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$35.45
|
| Rate for Payer: Molina Healthcare Passport |
$34.75
|
| Rate for Payer: Multiplan PHCS |
$615.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.44
|
| Rate for Payer: UHCCP Medicaid |
$45.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$80.34
|
|
|
PRO FE 180 MG CAPSULE
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 66594077701
|
| Hospital Charge Code |
25001238
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.66
|
| Rate for Payer: First Health Commercial |
$4.19
|
| Rate for Payer: Humana Commercial |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.88
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Payer |
$3.88
|
|
|
PRO FE 180 MG CAPSULE
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 66594077701
|
| Hospital Charge Code |
25001238
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.66
|
| Rate for Payer: First Health Commercial |
$4.19
|
| Rate for Payer: Humana Commercial |
$3.75
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.88
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Payer |
$3.88
|
|
|
PROFEMR CLC Z STM S1 EXT SH NK
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S1 EXT SH NK
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S1 STD SH NK
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S1 STD SH NK
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S2 EXT SH NK
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S2 EXT SH NK
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S2 STD SH NK
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S2 STD SH NK
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S3 EXT SH NK
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
PROFEMR CLC Z STM S3 EXT SH NK
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
