|
SELF PAY CT SCREEN COR ART(T
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
350T0090
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem Medicaid |
$103.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| 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 |
$158.88
|
| 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 |
$190.66
|
| 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 |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
SELF PAY CT SCREEN COR ART(T
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
350T0090
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$39.00 |
| 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 |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
SELF REF BILAT SCREEN WITH CAD
|
Facility
|
OP
|
$643.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
40100014
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$83.59 |
| Max. Negotiated Rate |
$617.28 |
| Rate for Payer: Aetna Commercial |
$495.11
|
| Rate for Payer: Anthem Medicaid |
$221.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$501.54
|
| Rate for Payer: Cash Price |
$321.50
|
| Rate for Payer: Cigna Commercial |
$533.69
|
| Rate for Payer: First Health Commercial |
$610.85
|
| Rate for Payer: Humana Commercial |
$546.55
|
| Rate for Payer: Humana KY Medicaid |
$221.13
|
| Rate for Payer: Kentucky WC Medicaid |
$223.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$527.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$474.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$225.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$565.84
|
| Rate for Payer: Ohio Health Group HMO |
$482.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$199.33
|
| Rate for Payer: PHCS Commercial |
$617.28
|
| Rate for Payer: United Healthcare All Payer |
$565.84
|
|
|
SELF REF BILAT SCREEN WITH CAD
|
Facility
|
IP
|
$643.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
40100014
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$83.59 |
| Max. Negotiated Rate |
$617.28 |
| Rate for Payer: Aetna Commercial |
$495.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$501.54
|
| Rate for Payer: Cash Price |
$321.50
|
| Rate for Payer: Cigna Commercial |
$533.69
|
| Rate for Payer: First Health Commercial |
$610.85
|
| Rate for Payer: Humana Commercial |
$546.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$527.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$474.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$192.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$565.84
|
| Rate for Payer: Ohio Health Group HMO |
$482.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$128.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$199.33
|
| Rate for Payer: PHCS Commercial |
$617.28
|
| Rate for Payer: United Healthcare All Payer |
$565.84
|
|
|
SELF REF BILAT SCREEN WITH CAD
|
Professional
|
Both
|
$643.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
40100014
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$643.00 |
| Rate for Payer: Anthem Medicaid |
$103.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$643.00
|
| Rate for Payer: Cash Price |
$321.50
|
| Rate for Payer: Cash Price |
$321.50
|
| Rate for Payer: Cigna Commercial |
$214.76
|
| Rate for Payer: Humana Medicaid |
$103.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.40
|
| Rate for Payer: Molina Healthcare Passport |
$103.33
|
| Rate for Payer: Multiplan PHCS |
$385.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$450.10
|
| Rate for Payer: UHCCP Medicaid |
$225.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.36
|
|
|
SELF REF BILAT SCREEN WITH CAD
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
401T0014
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$401.28 |
| Rate for Payer: Aetna Commercial |
$321.86
|
| Rate for Payer: Anthem Medicaid |
$143.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$326.04
|
| Rate for Payer: Cash Price |
$209.00
|
| Rate for Payer: Cigna Commercial |
$346.94
|
| Rate for Payer: First Health Commercial |
$397.10
|
| Rate for Payer: Humana Commercial |
$355.30
|
| Rate for Payer: Humana KY Medicaid |
$143.75
|
| Rate for Payer: Kentucky WC Medicaid |
$145.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$342.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$308.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$367.84
|
| Rate for Payer: Ohio Health Group HMO |
$313.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.58
|
| Rate for Payer: PHCS Commercial |
$401.28
|
| Rate for Payer: United Healthcare All Payer |
$367.84
|
|
|
SELF REF BILAT SCREEN WITH CAD
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
401P0014
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$67.70 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Anthem Medicaid |
$103.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$214.76
|
| Rate for Payer: Humana Medicaid |
$103.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$67.70
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$105.40
|
| Rate for Payer: Molina Healthcare Passport |
$103.33
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.36
|
|
|
SELF REF BILAT SCREEN WITH CAD
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
HCPCS 77067
|
| Hospital Charge Code |
401T0014
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$54.34 |
| Max. Negotiated Rate |
$401.28 |
| Rate for Payer: Aetna Commercial |
$321.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$326.04
|
| Rate for Payer: Cash Price |
$209.00
|
| Rate for Payer: Cigna Commercial |
$346.94
|
| Rate for Payer: First Health Commercial |
$397.10
|
| Rate for Payer: Humana Commercial |
$355.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$342.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$308.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$125.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$367.84
|
| Rate for Payer: Ohio Health Group HMO |
$313.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.58
|
| Rate for Payer: PHCS Commercial |
$401.28
|
| Rate for Payer: United Healthcare All Payer |
$367.84
|
|
|
SELF RETAINING DRIVER
|
Facility
|
IP
|
$3,512.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
SELF RETAINING DRIVER
|
Facility
|
OP
|
$3,512.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem Medicaid |
$1,207.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Humana KY Medicaid |
$1,207.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,220.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,232.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
SELSUN (SELENIUM) 2.5% LOT 4OZ
|
Facility
|
IP
|
$8.49
|
|
|
Service Code
|
NDC 45802004064
|
| Hospital Charge Code |
25001377
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$8.15 |
| Rate for Payer: Aetna Commercial |
$6.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.62
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna Commercial |
$7.05
|
| Rate for Payer: First Health Commercial |
$8.07
|
| Rate for Payer: Humana Commercial |
$7.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.47
|
| Rate for Payer: Ohio Health Group HMO |
$6.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.63
|
| Rate for Payer: PHCS Commercial |
$8.15
|
| Rate for Payer: United Healthcare All Payer |
$7.47
|
|
|
SELSUN (SELENIUM) 2.5% LOT 4OZ
|
Facility
|
OP
|
$8.49
|
|
|
Service Code
|
NDC 45802004064
|
| Hospital Charge Code |
25001377
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.10 |
| Max. Negotiated Rate |
$8.15 |
| Rate for Payer: Aetna Commercial |
$6.54
|
| Rate for Payer: Anthem Medicaid |
$2.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.62
|
| Rate for Payer: Cash Price |
$4.24
|
| Rate for Payer: Cigna Commercial |
$7.05
|
| Rate for Payer: First Health Commercial |
$8.07
|
| Rate for Payer: Humana Commercial |
$7.22
|
| Rate for Payer: Humana KY Medicaid |
$2.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.47
|
| Rate for Payer: Ohio Health Group HMO |
$6.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.63
|
| Rate for Payer: PHCS Commercial |
$8.15
|
| Rate for Payer: United Healthcare All Payer |
$7.47
|
|
|
SEMITENDINOSUS IRRADIATED
|
Facility
|
OP
|
$8,877.25
|
|
|
Service Code
|
HCPCS C9356
|
| Hospital Charge Code |
27000132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,154.04 |
| Max. Negotiated Rate |
$8,522.16 |
| Rate for Payer: Aetna Commercial |
$6,835.48
|
| Rate for Payer: Anthem Medicaid |
$3,052.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,924.26
|
| Rate for Payer: Cash Price |
$4,438.62
|
| Rate for Payer: Cigna Commercial |
$7,368.12
|
| Rate for Payer: First Health Commercial |
$8,433.39
|
| Rate for Payer: Humana Commercial |
$7,545.66
|
| Rate for Payer: Humana KY Medicaid |
$3,052.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3,083.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,279.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,551.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,663.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,114.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,811.98
|
| Rate for Payer: Ohio Health Group HMO |
$6,657.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,154.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,751.95
|
| Rate for Payer: PHCS Commercial |
$8,522.16
|
| Rate for Payer: United Healthcare All Payer |
$7,811.98
|
|
|
SEMITENDINOSUS IRRADIATED
|
Facility
|
IP
|
$8,877.25
|
|
|
Service Code
|
HCPCS C9356
|
| Hospital Charge Code |
27000132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,154.04 |
| Max. Negotiated Rate |
$8,522.16 |
| Rate for Payer: Aetna Commercial |
$6,835.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,924.26
|
| Rate for Payer: Cash Price |
$4,438.62
|
| Rate for Payer: Cigna Commercial |
$7,368.12
|
| Rate for Payer: First Health Commercial |
$8,433.39
|
| Rate for Payer: Humana Commercial |
$7,545.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,279.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,551.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,663.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,811.98
|
| Rate for Payer: Ohio Health Group HMO |
$6,657.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,154.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,751.95
|
| Rate for Payer: PHCS Commercial |
$8,522.16
|
| Rate for Payer: United Healthcare All Payer |
$7,811.98
|
|
|
SENOKOT S (DOCUSATE NA/SE 1TAB
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 536124801
|
| Hospital Charge Code |
25001380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
SENOKOT S (DOCUSATE NA/SE 1TAB
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
NDC 536124801
|
| Hospital Charge Code |
25001380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
SENOKOT (SENNA) 187 187MG/1TAB
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 904725261
|
| Hospital Charge Code |
25001378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
SENOKOT (SENNA) 187 187MG/1TAB
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 904725261
|
| Hospital Charge Code |
25001378
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
SENOKOT (SENNA) SYRUP 5 ML 5ML
|
Facility
|
OP
|
$4.37
|
|
|
Service Code
|
NDC 71399823708
|
| Hospital Charge Code |
25001379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
SENOKOT (SENNA) SYRUP 5 ML 5ML
|
Facility
|
IP
|
$4.37
|
|
|
Service Code
|
NDC 71399823708
|
| Hospital Charge Code |
25001379
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
SENSATN PLUS 40CC BALLOON PUMP
|
Facility
|
OP
|
$5,584.68
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$726.01 |
| Max. Negotiated Rate |
$5,361.29 |
| Rate for Payer: Aetna Commercial |
$4,300.20
|
| Rate for Payer: Anthem Medicaid |
$1,920.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,356.05
|
| Rate for Payer: Cash Price |
$2,792.34
|
| Rate for Payer: Cigna Commercial |
$4,635.28
|
| Rate for Payer: First Health Commercial |
$5,305.45
|
| Rate for Payer: Humana Commercial |
$4,746.98
|
| Rate for Payer: Humana KY Medicaid |
$1,920.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,940.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,579.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,121.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,675.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,959.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,914.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,188.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,116.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,731.25
|
| Rate for Payer: PHCS Commercial |
$5,361.29
|
| Rate for Payer: United Healthcare All Payer |
$4,914.52
|
|
|
SENSATN PLUS 40CC BALLOON PUMP
|
Facility
|
IP
|
$5,584.68
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$726.01 |
| Max. Negotiated Rate |
$5,361.29 |
| Rate for Payer: Aetna Commercial |
$4,300.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,356.05
|
| Rate for Payer: Cash Price |
$2,792.34
|
| Rate for Payer: Cigna Commercial |
$4,635.28
|
| Rate for Payer: First Health Commercial |
$5,305.45
|
| Rate for Payer: Humana Commercial |
$4,746.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,579.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,121.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,675.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,914.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,188.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,116.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,731.25
|
| Rate for Payer: PHCS Commercial |
$5,361.29
|
| Rate for Payer: United Healthcare All Payer |
$4,914.52
|
|
|
SENSATN PLUS 50CC BALLOON PUMP
|
Facility
|
OP
|
$5,584.68
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$726.01 |
| Max. Negotiated Rate |
$5,361.29 |
| Rate for Payer: Aetna Commercial |
$4,300.20
|
| Rate for Payer: Anthem Medicaid |
$1,920.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,356.05
|
| Rate for Payer: Cash Price |
$2,792.34
|
| Rate for Payer: Cigna Commercial |
$4,635.28
|
| Rate for Payer: First Health Commercial |
$5,305.45
|
| Rate for Payer: Humana Commercial |
$4,746.98
|
| Rate for Payer: Humana KY Medicaid |
$1,920.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,940.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,579.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,121.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,675.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,959.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,914.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,188.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,116.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,731.25
|
| Rate for Payer: PHCS Commercial |
$5,361.29
|
| Rate for Payer: United Healthcare All Payer |
$4,914.52
|
|
|
SENSATN PLUS 50CC BALLOON PUMP
|
Facility
|
IP
|
$5,584.68
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$726.01 |
| Max. Negotiated Rate |
$5,361.29 |
| Rate for Payer: Aetna Commercial |
$4,300.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,356.05
|
| Rate for Payer: Cash Price |
$2,792.34
|
| Rate for Payer: Cigna Commercial |
$4,635.28
|
| Rate for Payer: First Health Commercial |
$5,305.45
|
| Rate for Payer: Humana Commercial |
$4,746.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,579.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,121.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,675.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,914.52
|
| Rate for Payer: Ohio Health Group HMO |
$4,188.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,116.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,731.25
|
| Rate for Payer: PHCS Commercial |
$5,361.29
|
| Rate for Payer: United Healthcare All Payer |
$4,914.52
|
|
|
SENSITIVI DISK METHOD PER PLAT
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
HCPCS 87184
|
| Hospital Charge Code |
30001320
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.63
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
|
