|
BICILLIN LA 100K (1.2MMU)
|
Professional
|
Both
|
$50.11
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
63600015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.54 |
| Max. Negotiated Rate |
$50.11 |
| Rate for Payer: Aetna Commercial |
$20.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.11
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$21.60
|
| Rate for Payer: Multiplan PHCS |
$30.07
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.08
|
| Rate for Payer: UHCCP Medicaid |
$17.54
|
|
|
BICILLIN LA 100K (1.2MMU)
|
Facility
|
OP
|
$657.14
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
25001893
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$630.85 |
| Rate for Payer: Aetna Commercial |
$506.00
|
| Rate for Payer: Anthem Medicaid |
$225.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$512.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.34
|
| Rate for Payer: Cash Price |
$328.57
|
| Rate for Payer: Cash Price |
$328.57
|
| Rate for Payer: Cigna Commercial |
$545.43
|
| Rate for Payer: First Health Commercial |
$624.28
|
| Rate for Payer: Humana Commercial |
$558.57
|
| Rate for Payer: Humana KY Medicaid |
$225.99
|
| Rate for Payer: Humana Medicare Advantage |
$21.73
|
| Rate for Payer: Kentucky WC Medicaid |
$228.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$538.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$484.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$230.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$578.28
|
| Rate for Payer: Ohio Health Group HMO |
$492.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.71
|
| Rate for Payer: PHCS Commercial |
$630.85
|
| Rate for Payer: United Healthcare All Payer |
$578.28
|
|
|
BICILLIN LA 100K (1.2MMU)
|
Facility
|
IP
|
$657.14
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
25001893
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.43 |
| Max. Negotiated Rate |
$630.85 |
| Rate for Payer: Aetna Commercial |
$506.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$512.57
|
| Rate for Payer: Cash Price |
$328.57
|
| Rate for Payer: Cigna Commercial |
$545.43
|
| Rate for Payer: First Health Commercial |
$624.28
|
| Rate for Payer: Humana Commercial |
$558.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$538.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$484.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$578.28
|
| Rate for Payer: Ohio Health Group HMO |
$492.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$203.71
|
| Rate for Payer: PHCS Commercial |
$630.85
|
| Rate for Payer: United Healthcare All Payer |
$578.28
|
|
|
BICILLIN LA 100K (1.2MMU)
|
Facility
|
IP
|
$50.11
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
636T0015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$48.11 |
| Rate for Payer: Aetna Commercial |
$38.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.09
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cigna Commercial |
$41.59
|
| Rate for Payer: First Health Commercial |
$47.60
|
| Rate for Payer: Humana Commercial |
$42.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.10
|
| Rate for Payer: Ohio Health Group HMO |
$37.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.53
|
| Rate for Payer: PHCS Commercial |
$48.11
|
| Rate for Payer: United Healthcare All Payer |
$44.10
|
|
|
BICILLIN LA 100K (1.2MMU)
|
Facility
|
OP
|
$50.11
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
63600015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$48.11 |
| Rate for Payer: Aetna Commercial |
$38.58
|
| Rate for Payer: Anthem Medicaid |
$17.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.34
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cigna Commercial |
$41.59
|
| Rate for Payer: First Health Commercial |
$47.60
|
| Rate for Payer: Humana Commercial |
$42.59
|
| Rate for Payer: Humana KY Medicaid |
$17.23
|
| Rate for Payer: Humana Medicare Advantage |
$21.73
|
| Rate for Payer: Kentucky WC Medicaid |
$17.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.10
|
| Rate for Payer: Ohio Health Group HMO |
$37.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.53
|
| Rate for Payer: PHCS Commercial |
$48.11
|
| Rate for Payer: United Healthcare All Payer |
$44.10
|
|
|
BICILLIN LA 100K (1.2MMU)
|
Facility
|
OP
|
$50.11
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
636T0015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$48.11 |
| Rate for Payer: Aetna Commercial |
$38.58
|
| Rate for Payer: Anthem Medicaid |
$17.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.34
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cigna Commercial |
$41.59
|
| Rate for Payer: First Health Commercial |
$47.60
|
| Rate for Payer: Humana Commercial |
$42.59
|
| Rate for Payer: Humana KY Medicaid |
$17.23
|
| Rate for Payer: Humana Medicare Advantage |
$21.73
|
| Rate for Payer: Kentucky WC Medicaid |
$17.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.10
|
| Rate for Payer: Ohio Health Group HMO |
$37.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.53
|
| Rate for Payer: PHCS Commercial |
$48.11
|
| Rate for Payer: United Healthcare All Payer |
$44.10
|
|
|
BICILLIN LA 100K (1.2MMU)
|
Facility
|
IP
|
$50.11
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
63600015
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.51 |
| Max. Negotiated Rate |
$48.11 |
| Rate for Payer: Aetna Commercial |
$38.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$39.09
|
| Rate for Payer: Cash Price |
$25.06
|
| Rate for Payer: Cigna Commercial |
$41.59
|
| Rate for Payer: First Health Commercial |
$47.60
|
| Rate for Payer: Humana Commercial |
$42.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$41.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$36.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$44.10
|
| Rate for Payer: Ohio Health Group HMO |
$37.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.53
|
| Rate for Payer: PHCS Commercial |
$48.11
|
| Rate for Payer: United Healthcare All Payer |
$44.10
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Facility
|
IP
|
$1,049.55
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
25001891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$136.44 |
| Max. Negotiated Rate |
$1,007.57 |
| Rate for Payer: Aetna Commercial |
$808.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$818.65
|
| Rate for Payer: Cash Price |
$524.78
|
| Rate for Payer: Cigna Commercial |
$871.13
|
| Rate for Payer: First Health Commercial |
$997.07
|
| Rate for Payer: Humana Commercial |
$892.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$860.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$774.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$314.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$923.60
|
| Rate for Payer: Ohio Health Group HMO |
$787.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$209.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$325.36
|
| Rate for Payer: PHCS Commercial |
$1,007.57
|
| Rate for Payer: United Healthcare All Payer |
$923.60
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Facility
|
IP
|
$39.59
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
63600013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$38.01 |
| Rate for Payer: Aetna Commercial |
$30.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.88
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$32.86
|
| Rate for Payer: First Health Commercial |
$37.61
|
| Rate for Payer: Humana Commercial |
$33.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.84
|
| Rate for Payer: Ohio Health Group HMO |
$29.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.27
|
| Rate for Payer: PHCS Commercial |
$38.01
|
| Rate for Payer: United Healthcare All Payer |
$34.84
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Facility
|
OP
|
$39.59
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
636T0013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$38.01 |
| Rate for Payer: Aetna Commercial |
$30.48
|
| Rate for Payer: Anthem Medicaid |
$13.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.34
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$32.86
|
| Rate for Payer: First Health Commercial |
$37.61
|
| Rate for Payer: Humana Commercial |
$33.65
|
| Rate for Payer: Humana KY Medicaid |
$13.62
|
| Rate for Payer: Humana Medicare Advantage |
$21.73
|
| Rate for Payer: Kentucky WC Medicaid |
$13.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.84
|
| Rate for Payer: Ohio Health Group HMO |
$29.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.27
|
| Rate for Payer: PHCS Commercial |
$38.01
|
| Rate for Payer: United Healthcare All Payer |
$34.84
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Professional
|
Both
|
$39.59
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
63600013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$39.59 |
| Rate for Payer: Aetna Commercial |
$20.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$39.59
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$21.60
|
| Rate for Payer: Multiplan PHCS |
$23.75
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$27.71
|
| Rate for Payer: UHCCP Medicaid |
$13.86
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Facility
|
IP
|
$39.59
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
636T0013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$38.01 |
| Rate for Payer: Aetna Commercial |
$30.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.88
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$32.86
|
| Rate for Payer: First Health Commercial |
$37.61
|
| Rate for Payer: Humana Commercial |
$33.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.84
|
| Rate for Payer: Ohio Health Group HMO |
$29.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.27
|
| Rate for Payer: PHCS Commercial |
$38.01
|
| Rate for Payer: United Healthcare All Payer |
$34.84
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Facility
|
OP
|
$1,049.55
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
25001891
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$1,007.57 |
| Rate for Payer: Aetna Commercial |
$808.15
|
| Rate for Payer: Anthem Medicaid |
$360.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$818.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.34
|
| Rate for Payer: Cash Price |
$524.78
|
| Rate for Payer: Cash Price |
$524.78
|
| Rate for Payer: Cigna Commercial |
$871.13
|
| Rate for Payer: First Health Commercial |
$997.07
|
| Rate for Payer: Humana Commercial |
$892.12
|
| Rate for Payer: Humana KY Medicaid |
$360.94
|
| Rate for Payer: Humana Medicare Advantage |
$21.73
|
| Rate for Payer: Kentucky WC Medicaid |
$364.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$860.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$774.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$368.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$923.60
|
| Rate for Payer: Ohio Health Group HMO |
$787.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$209.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$325.36
|
| Rate for Payer: PHCS Commercial |
$1,007.57
|
| Rate for Payer: United Healthcare All Payer |
$923.60
|
|
|
BICILLIN LA 100K (2.4MMU)
|
Facility
|
OP
|
$39.59
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
63600013
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.15 |
| Max. Negotiated Rate |
$38.01 |
| Rate for Payer: Aetna Commercial |
$30.48
|
| Rate for Payer: Anthem Medicaid |
$13.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$21.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$30.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$29.34
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: Cigna Commercial |
$32.86
|
| Rate for Payer: First Health Commercial |
$37.61
|
| Rate for Payer: Humana Commercial |
$33.65
|
| Rate for Payer: Humana KY Medicaid |
$13.62
|
| Rate for Payer: Humana Medicare Advantage |
$21.73
|
| Rate for Payer: Kentucky WC Medicaid |
$13.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.84
|
| Rate for Payer: Ohio Health Group HMO |
$29.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.27
|
| Rate for Payer: PHCS Commercial |
$38.01
|
| Rate for Payer: United Healthcare All Payer |
$34.84
|
|
|
BICITRA SF(CITRIC AC/NA C 30ML
|
Facility
|
IP
|
$5.09
|
|
|
Service Code
|
NDC 121059516
|
| Hospital Charge Code |
25000336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
BICITRA SF(CITRIC AC/NA C 30ML
|
Facility
|
OP
|
$5.09
|
|
|
Service Code
|
NDC 121059516
|
| Hospital Charge Code |
25000336
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.89 |
| Rate for Payer: Aetna Commercial |
$3.92
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.97
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.84
|
| Rate for Payer: Humana Commercial |
$4.33
|
| Rate for Payer: Humana KY Medicaid |
$1.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.48
|
| Rate for Payer: Ohio Health Group HMO |
$3.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.58
|
| Rate for Payer: PHCS Commercial |
$4.89
|
| Rate for Payer: United Healthcare All Payer |
$4.48
|
|
|
BICNU 100MG VIAL
|
Facility
|
IP
|
$2,943.00
|
|
|
Service Code
|
HCPCS J9050
|
| Hospital Charge Code |
25002581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$382.59 |
| Max. Negotiated Rate |
$2,825.28 |
| Rate for Payer: Aetna Commercial |
$2,266.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,295.54
|
| Rate for Payer: Cash Price |
$1,471.50
|
| Rate for Payer: Cigna Commercial |
$2,442.69
|
| Rate for Payer: First Health Commercial |
$2,795.85
|
| Rate for Payer: Humana Commercial |
$2,501.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,413.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,171.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$882.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,589.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,207.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$912.33
|
| Rate for Payer: PHCS Commercial |
$2,825.28
|
| Rate for Payer: United Healthcare All Payer |
$2,589.84
|
|
|
BICNU 100MG VIAL
|
Facility
|
OP
|
$2,943.00
|
|
|
Service Code
|
HCPCS J9050
|
| Hospital Charge Code |
25002581
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$271.46 |
| Max. Negotiated Rate |
$2,825.28 |
| Rate for Payer: Aetna Commercial |
$2,266.11
|
| Rate for Payer: Anthem Medicaid |
$1,012.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,295.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.48
|
| Rate for Payer: Cash Price |
$1,471.50
|
| Rate for Payer: Cash Price |
$1,471.50
|
| Rate for Payer: Cigna Commercial |
$2,442.69
|
| Rate for Payer: First Health Commercial |
$2,795.85
|
| Rate for Payer: Humana Commercial |
$2,501.55
|
| Rate for Payer: Humana KY Medicaid |
$1,012.10
|
| Rate for Payer: Humana Medicare Advantage |
$271.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,022.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,413.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,171.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,032.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,589.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,207.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$588.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$912.33
|
| Rate for Payer: PHCS Commercial |
$2,825.28
|
| Rate for Payer: United Healthcare All Payer |
$2,589.84
|
|
|
BICORTICAL TF SHAFT 3.5MM
|
Facility
|
IP
|
$3,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$417.95 |
| Max. Negotiated Rate |
$3,086.40 |
| Rate for Payer: Aetna Commercial |
$2,475.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,507.70
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cigna Commercial |
$2,668.45
|
| Rate for Payer: First Health Commercial |
$3,054.25
|
| Rate for Payer: Humana Commercial |
$2,732.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,636.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,372.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,829.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,411.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$643.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$417.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$996.65
|
| Rate for Payer: PHCS Commercial |
$3,086.40
|
| Rate for Payer: United Healthcare All Payer |
$2,829.20
|
|
|
BICORTICAL TF SHAFT 3.5MM
|
Facility
|
OP
|
$3,215.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$417.95 |
| Max. Negotiated Rate |
$3,086.40 |
| Rate for Payer: Aetna Commercial |
$2,475.55
|
| Rate for Payer: Anthem Medicaid |
$1,105.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,507.70
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cigna Commercial |
$2,668.45
|
| Rate for Payer: First Health Commercial |
$3,054.25
|
| Rate for Payer: Humana Commercial |
$2,732.75
|
| Rate for Payer: Humana KY Medicaid |
$1,105.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,116.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,636.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,372.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,127.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,829.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,411.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$643.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$417.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$996.65
|
| Rate for Payer: PHCS Commercial |
$3,086.40
|
| Rate for Payer: United Healthcare All Payer |
$2,829.20
|
|
|
BIER BLOCK
|
Facility
|
OP
|
$2,871.57
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102380
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$256.12 |
| Max. Negotiated Rate |
$2,756.71 |
| Rate for Payer: Aetna Commercial |
$2,211.11
|
| Rate for Payer: Anthem Medicaid |
$987.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,239.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cigna Commercial |
$2,383.40
|
| Rate for Payer: First Health Commercial |
$2,727.99
|
| Rate for Payer: Humana Commercial |
$2,440.83
|
| Rate for Payer: Humana KY Medicaid |
$987.53
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$997.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,354.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,119.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,007.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,526.98
|
| Rate for Payer: Ohio Health Group HMO |
$2,153.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$574.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$373.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$890.19
|
| Rate for Payer: PHCS Commercial |
$2,756.71
|
| Rate for Payer: United Healthcare All Payer |
$2,526.98
|
|
|
BIER BLOCK
|
Facility
|
IP
|
$2,871.57
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102380
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$373.30 |
| Max. Negotiated Rate |
$2,756.71 |
| Rate for Payer: Aetna Commercial |
$2,211.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,239.82
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cigna Commercial |
$2,383.40
|
| Rate for Payer: First Health Commercial |
$2,727.99
|
| Rate for Payer: Humana Commercial |
$2,440.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,354.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,119.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$861.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,526.98
|
| Rate for Payer: Ohio Health Group HMO |
$2,153.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$574.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$373.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$890.19
|
| Rate for Payer: PHCS Commercial |
$2,756.71
|
| Rate for Payer: United Healthcare All Payer |
$2,526.98
|
|
|
BIER BLOCK
|
Professional
|
Both
|
$2,871.57
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
76102380
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,871.57 |
| Rate for Payer: Anthem Medicaid |
$2,800.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,871.57
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$2,800.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$2,856.00
|
| Rate for Payer: Molina Healthcare Passport |
$2,800.00
|
| Rate for Payer: Multiplan PHCS |
$1,722.94
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,010.10
|
| Rate for Payer: UHCCP Medicaid |
$1,005.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2,828.00
|
|
|
BIER BLOCK(T
|
Facility
|
OP
|
$2,871.57
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
761T2380
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$256.12 |
| Max. Negotiated Rate |
$2,756.71 |
| Rate for Payer: Aetna Commercial |
$2,211.11
|
| Rate for Payer: Anthem Medicaid |
$987.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$256.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,239.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$358.57
|
| Rate for Payer: CareSource Just4Me Medicare |
$345.76
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cigna Commercial |
$2,383.40
|
| Rate for Payer: First Health Commercial |
$2,727.99
|
| Rate for Payer: Humana Commercial |
$2,440.83
|
| Rate for Payer: Humana KY Medicaid |
$987.53
|
| Rate for Payer: Humana Medicare Advantage |
$256.12
|
| Rate for Payer: Kentucky WC Medicaid |
$997.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,354.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,119.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,007.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,526.98
|
| Rate for Payer: Ohio Health Group HMO |
$2,153.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$574.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$373.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$890.19
|
| Rate for Payer: PHCS Commercial |
$2,756.71
|
| Rate for Payer: United Healthcare All Payer |
$2,526.98
|
|
|
BIER BLOCK(T
|
Facility
|
IP
|
$2,871.57
|
|
|
Service Code
|
HCPCS 64999
|
| Hospital Charge Code |
761T2380
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$373.30 |
| Max. Negotiated Rate |
$2,756.71 |
| Rate for Payer: Aetna Commercial |
$2,211.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,239.82
|
| Rate for Payer: Cash Price |
$1,435.79
|
| Rate for Payer: Cigna Commercial |
$2,383.40
|
| Rate for Payer: First Health Commercial |
$2,727.99
|
| Rate for Payer: Humana Commercial |
$2,440.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,354.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,119.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$861.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,526.98
|
| Rate for Payer: Ohio Health Group HMO |
$2,153.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$574.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$373.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$890.19
|
| Rate for Payer: PHCS Commercial |
$2,756.71
|
| Rate for Payer: United Healthcare All Payer |
$2,526.98
|
|
