|
REV POR 170MM STR SZ 20
|
Facility
|
IP
|
$15,102.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,963.36 |
| Max. Negotiated Rate |
$14,498.67 |
| Rate for Payer: Aetna Commercial |
$11,629.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,780.17
|
| Rate for Payer: Cash Price |
$7,551.39
|
| Rate for Payer: Cigna Commercial |
$12,535.31
|
| Rate for Payer: First Health Commercial |
$14,347.64
|
| Rate for Payer: Humana Commercial |
$12,837.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,384.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,145.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,530.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,290.45
|
| Rate for Payer: Ohio Health Group HMO |
$11,327.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,020.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,963.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,681.86
|
| Rate for Payer: PHCS Commercial |
$14,498.67
|
| Rate for Payer: United Healthcare All Payer |
$13,290.45
|
|
|
REVSC OPN/PRQ TIB/PERO STEN(P
|
Professional
|
Both
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
761P1558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.13 |
| Max. Negotiated Rate |
$8,000.00 |
| Rate for Payer: Aetna Commercial |
$475.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$143.13
|
| Rate for Payer: Anthem Medicaid |
$253.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$8,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$538.20
|
| Rate for Payer: Healthspan PPO |
$3,613.90
|
| Rate for Payer: Humana Medicaid |
$253.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$259.06
|
| Rate for Payer: Molina Healthcare Passport |
$253.98
|
| Rate for Payer: Multiplan PHCS |
$4,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,600.00
|
| Rate for Payer: UHCCP Medicaid |
$150.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$256.52
|
|
|
REVSC OPN/PRQ TIB/PERO STENT
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
76101558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$7,680.00 |
| Rate for Payer: Aetna Commercial |
$6,160.00
|
| Rate for Payer: Anthem Medicaid |
$2,751.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$6,640.00
|
| Rate for Payer: First Health Commercial |
$7,600.00
|
| Rate for Payer: Humana Commercial |
$6,800.00
|
| Rate for Payer: Humana KY Medicaid |
$2,751.20
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,560.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.00
|
| Rate for Payer: PHCS Commercial |
$7,680.00
|
| Rate for Payer: United Healthcare All Payer |
$7,040.00
|
|
|
REVSC OPN/PRQ TIB/PERO STENT
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
76101558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,040.00 |
| Max. Negotiated Rate |
$7,680.00 |
| Rate for Payer: Aetna Commercial |
$6,160.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$6,640.00
|
| Rate for Payer: First Health Commercial |
$7,600.00
|
| Rate for Payer: Humana Commercial |
$6,800.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,560.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.00
|
| Rate for Payer: PHCS Commercial |
$7,680.00
|
| Rate for Payer: United Healthcare All Payer |
$7,040.00
|
|
|
REVSC OPN/PRQ TIB/PERO STENT
|
Professional
|
Both
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
76101558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.13 |
| Max. Negotiated Rate |
$8,000.00 |
| Rate for Payer: Aetna Commercial |
$475.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$143.13
|
| Rate for Payer: Anthem Medicaid |
$253.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$8,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$538.20
|
| Rate for Payer: Healthspan PPO |
$3,613.90
|
| Rate for Payer: Humana Medicaid |
$253.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$259.06
|
| Rate for Payer: Molina Healthcare Passport |
$253.98
|
| Rate for Payer: Multiplan PHCS |
$4,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,600.00
|
| Rate for Payer: UHCCP Medicaid |
$150.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$256.52
|
|
|
Revuna 1.5 cc
|
Professional
|
Both
|
$1,040.00
|
|
| Hospital Charge Code |
22200704
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$1,040.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,040.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$728.00
|
| Rate for Payer: UHCCP Medicaid |
$364.00
|
|
|
Revuna 3.0 cc
|
Professional
|
Both
|
$2,060.00
|
|
| Hospital Charge Code |
22200705
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$721.00 |
| Max. Negotiated Rate |
$2,060.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,060.00
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Multiplan PHCS |
$1,236.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,442.00
|
| Rate for Payer: UHCCP Medicaid |
$721.00
|
|
|
REXULTI 0.25MG TABLET
|
Facility
|
OP
|
$87.05
|
|
|
Service Code
|
NDC 59148003513
|
| Hospital Charge Code |
25003411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem Medicaid |
$29.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Humana KY Medicaid |
$29.94
|
| Rate for Payer: Kentucky WC Medicaid |
$30.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 0.25MG TABLET
|
Facility
|
IP
|
$87.05
|
|
|
Service Code
|
NDC 59148003513
|
| Hospital Charge Code |
25003411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 0.5MG TABLET
|
Facility
|
OP
|
$87.05
|
|
|
Service Code
|
NDC 59148003613
|
| Hospital Charge Code |
25003412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem Medicaid |
$29.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Humana KY Medicaid |
$29.94
|
| Rate for Payer: Kentucky WC Medicaid |
$30.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 0.5MG TABLET
|
Facility
|
IP
|
$87.05
|
|
|
Service Code
|
NDC 59148003613
|
| Hospital Charge Code |
25003412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 1MG TABLET
|
Facility
|
IP
|
$87.05
|
|
|
Service Code
|
NDC 59148003713
|
| Hospital Charge Code |
25003413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 1MG TABLET
|
Facility
|
OP
|
$87.05
|
|
|
Service Code
|
NDC 59148003713
|
| Hospital Charge Code |
25003413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem Medicaid |
$29.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Humana KY Medicaid |
$29.94
|
| Rate for Payer: Kentucky WC Medicaid |
$30.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 2MG TABLET
|
Facility
|
OP
|
$87.05
|
|
|
Service Code
|
NDC 59148003813
|
| Hospital Charge Code |
25003414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem Medicaid |
$29.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Humana KY Medicaid |
$29.94
|
| Rate for Payer: Kentucky WC Medicaid |
$30.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 2MG TABLET
|
Facility
|
IP
|
$87.05
|
|
|
Service Code
|
NDC 59148003813
|
| Hospital Charge Code |
25003414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 3MG TABLET
|
Facility
|
IP
|
$87.05
|
|
|
Service Code
|
NDC 59148003913
|
| Hospital Charge Code |
25003415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 3MG TABLET
|
Facility
|
OP
|
$87.05
|
|
|
Service Code
|
NDC 59148003913
|
| Hospital Charge Code |
25003415
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem Medicaid |
$29.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Humana KY Medicaid |
$29.94
|
| Rate for Payer: Kentucky WC Medicaid |
$30.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 4MG TABLET
|
Facility
|
OP
|
$87.05
|
|
|
Service Code
|
NDC 59148004013
|
| Hospital Charge Code |
25003416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem Medicaid |
$29.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Humana KY Medicaid |
$29.94
|
| Rate for Payer: Kentucky WC Medicaid |
$30.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
REXULTI 4MG TABLET
|
Facility
|
IP
|
$87.05
|
|
|
Service Code
|
NDC 59148004013
|
| Hospital Charge Code |
25003416
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.32 |
| Max. Negotiated Rate |
$83.57 |
| Rate for Payer: Aetna Commercial |
$67.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Cash Price |
$43.52
|
| Rate for Payer: Cigna Commercial |
$72.25
|
| Rate for Payer: First Health Commercial |
$82.70
|
| Rate for Payer: Humana Commercial |
$73.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.60
|
| Rate for Payer: Ohio Health Group HMO |
$65.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.99
|
| Rate for Payer: PHCS Commercial |
$83.57
|
| Rate for Payer: United Healthcare All Payer |
$76.60
|
|
|
RF ABLATION NRV SI JOINT
|
Professional
|
Both
|
$5,090.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
76102921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.64 |
| Max. Negotiated Rate |
$5,090.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$156.42
|
| Rate for Payer: Anthem Medicaid |
$155.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,090.00
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Humana Medicaid |
$155.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$250.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$158.75
|
| Rate for Payer: Molina Healthcare Passport |
$155.64
|
| Rate for Payer: Multiplan PHCS |
$3,054.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,563.00
|
| Rate for Payer: UHCCP Medicaid |
$164.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.20
|
|
|
RF ABLATION NRV SI JOINT
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
76102921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$661.70 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,018.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.90
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
RF ABLATION NRV SI JOINT
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
76102921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$661.70 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,018.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$661.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,577.90
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
RF ABLATION NRV SI JOINT (P
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
761P2921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.64 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$156.42
|
| Rate for Payer: Anthem Medicaid |
$155.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.00
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Humana Medicaid |
$155.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$250.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$158.75
|
| Rate for Payer: Molina Healthcare Passport |
$155.64
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.50
|
| Rate for Payer: UHCCP Medicaid |
$164.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.20
|
|
|
RF ABLATION NRV SI JOINT (T
|
Facility
|
IP
|
$4,615.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
761T2921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$599.95 |
| Max. Negotiated Rate |
$4,430.40 |
| Rate for Payer: Aetna Commercial |
$3,553.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,599.70
|
| Rate for Payer: Cash Price |
$2,307.50
|
| Rate for Payer: Cigna Commercial |
$3,830.45
|
| Rate for Payer: First Health Commercial |
$4,384.25
|
| Rate for Payer: Humana Commercial |
$3,922.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,784.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,405.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,384.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,061.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,461.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$923.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,430.65
|
| Rate for Payer: PHCS Commercial |
$4,430.40
|
| Rate for Payer: United Healthcare All Payer |
$4,061.20
|
|
|
RF ABLATION NRV SI JOINT (T
|
Facility
|
OP
|
$4,615.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
761T2921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$599.95 |
| Max. Negotiated Rate |
$4,430.40 |
| Rate for Payer: Aetna Commercial |
$3,553.55
|
| Rate for Payer: Anthem Medicaid |
$1,587.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,669.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,599.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,337.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,254.03
|
| Rate for Payer: Cash Price |
$2,307.50
|
| Rate for Payer: Cash Price |
$2,307.50
|
| Rate for Payer: Cigna Commercial |
$3,830.45
|
| Rate for Payer: First Health Commercial |
$4,384.25
|
| Rate for Payer: Humana Commercial |
$3,922.75
|
| Rate for Payer: Humana KY Medicaid |
$1,587.10
|
| Rate for Payer: Humana Medicare Advantage |
$1,669.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,603.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,784.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,405.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,003.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,618.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,061.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,461.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$923.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$599.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,430.65
|
| Rate for Payer: PHCS Commercial |
$4,430.40
|
| Rate for Payer: United Healthcare All Payer |
$4,061.20
|
|
