|
SEPTOPLASTY(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 30520
|
| Hospital Charge Code |
761P1132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.62 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$841.39
|
| Rate for Payer: Anthem Medicaid |
$376.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$787.50
|
| Rate for Payer: Healthspan PPO |
$709.56
|
| Rate for Payer: Humana Medicaid |
$376.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$777.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.15
|
| Rate for Payer: Molina Healthcare Passport |
$376.62
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.39
|
|
|
SEPTRA (TRIMETHOPRIM 10ML/10ML
|
Facility
|
IP
|
$119.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$114.39 |
| Rate for Payer: Aetna Commercial |
$91.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.94
|
| Rate for Payer: Cash Price |
$59.58
|
| Rate for Payer: Cigna Commercial |
$98.90
|
| Rate for Payer: First Health Commercial |
$113.20
|
| Rate for Payer: Humana Commercial |
$101.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.86
|
| Rate for Payer: Ohio Health Group HMO |
$89.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.94
|
| Rate for Payer: PHCS Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Payer |
$104.86
|
|
|
SEPTRA (TRIMETHOPRIM 10ML/10ML
|
Facility
|
OP
|
$119.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.49 |
| Max. Negotiated Rate |
$114.39 |
| Rate for Payer: Aetna Commercial |
$91.75
|
| Rate for Payer: Anthem Medicaid |
$40.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.94
|
| Rate for Payer: Cash Price |
$59.58
|
| Rate for Payer: Cigna Commercial |
$98.90
|
| Rate for Payer: First Health Commercial |
$113.20
|
| Rate for Payer: Humana Commercial |
$101.29
|
| Rate for Payer: Humana KY Medicaid |
$40.98
|
| Rate for Payer: Kentucky WC Medicaid |
$41.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.86
|
| Rate for Payer: Ohio Health Group HMO |
$89.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.94
|
| Rate for Payer: PHCS Commercial |
$114.39
|
| Rate for Payer: United Healthcare All Payer |
$104.86
|
|
|
SEPTRA(TRIMETH/SULFAMETH) 20ML
|
Facility
|
OP
|
$9.59
|
|
|
Service Code
|
NDC 121085416
|
| Hospital Charge Code |
25001382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.21 |
| Rate for Payer: Aetna Commercial |
$7.38
|
| Rate for Payer: Anthem Medicaid |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.96
|
| Rate for Payer: First Health Commercial |
$9.11
|
| Rate for Payer: Humana Commercial |
$8.15
|
| Rate for Payer: Humana KY Medicaid |
$3.30
|
| Rate for Payer: Kentucky WC Medicaid |
$3.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.44
|
| Rate for Payer: Ohio Health Group HMO |
$7.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$9.21
|
| Rate for Payer: United Healthcare All Payer |
$8.44
|
|
|
SEPTRA(TRIMETH/SULFAMETH) 20ML
|
Facility
|
IP
|
$9.59
|
|
|
Service Code
|
NDC 121085416
|
| Hospital Charge Code |
25001382
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.21 |
| Rate for Payer: Aetna Commercial |
$7.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.48
|
| Rate for Payer: Cash Price |
$4.80
|
| Rate for Payer: Cigna Commercial |
$7.96
|
| Rate for Payer: First Health Commercial |
$9.11
|
| Rate for Payer: Humana Commercial |
$8.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.44
|
| Rate for Payer: Ohio Health Group HMO |
$7.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.97
|
| Rate for Payer: PHCS Commercial |
$9.21
|
| Rate for Payer: United Healthcare All Payer |
$8.44
|
|
|
SERI SCAFFOLD 10CM*25CM
|
Facility
|
IP
|
$16,800.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,184.00 |
| Max. Negotiated Rate |
$16,128.00 |
| Rate for Payer: Aetna Commercial |
$12,936.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,104.00
|
| Rate for Payer: Cash Price |
$8,400.00
|
| Rate for Payer: Cigna Commercial |
$13,944.00
|
| Rate for Payer: First Health Commercial |
$15,960.00
|
| Rate for Payer: Humana Commercial |
$14,280.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,776.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,398.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,040.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,184.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,208.00
|
| Rate for Payer: PHCS Commercial |
$16,128.00
|
| Rate for Payer: United Healthcare All Payer |
$14,784.00
|
|
|
SERI SCAFFOLD 10CM*25CM
|
Facility
|
OP
|
$16,800.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,184.00 |
| Max. Negotiated Rate |
$16,128.00 |
| Rate for Payer: Aetna Commercial |
$12,936.00
|
| Rate for Payer: Anthem Medicaid |
$5,777.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,104.00
|
| Rate for Payer: Cash Price |
$8,400.00
|
| Rate for Payer: Cigna Commercial |
$13,944.00
|
| Rate for Payer: First Health Commercial |
$15,960.00
|
| Rate for Payer: Humana Commercial |
$14,280.00
|
| Rate for Payer: Humana KY Medicaid |
$5,777.52
|
| Rate for Payer: Kentucky WC Medicaid |
$5,836.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,776.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,398.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,040.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,893.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,184.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,208.00
|
| Rate for Payer: PHCS Commercial |
$16,128.00
|
| Rate for Payer: United Healthcare All Payer |
$14,784.00
|
|
|
SEROMYCIN 250MG CAPSULE
|
Facility
|
OP
|
$141.67
|
|
|
Service Code
|
NDC 13845120202
|
| Hospital Charge Code |
25001384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.42 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$109.09
|
| Rate for Payer: Anthem Medicaid |
$48.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.50
|
| Rate for Payer: Cash Price |
$70.83
|
| Rate for Payer: Cigna Commercial |
$117.59
|
| Rate for Payer: First Health Commercial |
$134.59
|
| Rate for Payer: Humana Commercial |
$120.42
|
| Rate for Payer: Humana KY Medicaid |
$48.72
|
| Rate for Payer: Kentucky WC Medicaid |
$49.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.67
|
| Rate for Payer: Ohio Health Group HMO |
$106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.92
|
| Rate for Payer: PHCS Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Payer |
$124.67
|
|
|
SEROMYCIN 250MG CAPSULE
|
Facility
|
IP
|
$141.67
|
|
|
Service Code
|
NDC 13845120202
|
| Hospital Charge Code |
25001384
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.42 |
| Max. Negotiated Rate |
$136.00 |
| Rate for Payer: Aetna Commercial |
$109.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$110.50
|
| Rate for Payer: Cash Price |
$70.83
|
| Rate for Payer: Cigna Commercial |
$117.59
|
| Rate for Payer: First Health Commercial |
$134.59
|
| Rate for Payer: Humana Commercial |
$120.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.67
|
| Rate for Payer: Ohio Health Group HMO |
$106.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.92
|
| Rate for Payer: PHCS Commercial |
$136.00
|
| Rate for Payer: United Healthcare All Payer |
$124.67
|
|
|
SEROQUEL 400MG EQUIV TABLET
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 68180045001
|
| Hospital Charge Code |
25003443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
SEROQUEL 400MG EQUIV TABLET
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 68180045001
|
| Hospital Charge Code |
25003443
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
SEROQUEL (QUETIAP FUM)100MGTAB
|
Facility
|
OP
|
$4.73
|
|
|
Service Code
|
NDC 60687034901
|
| Hospital Charge Code |
25001385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.69
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.49
|
| Rate for Payer: Humana Commercial |
$4.02
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.16
|
| Rate for Payer: Ohio Health Group HMO |
$3.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SEROQUEL (QUETIAP FUM)100MGTAB
|
Facility
|
IP
|
$4.73
|
|
|
Service Code
|
NDC 60687034901
|
| Hospital Charge Code |
25001385
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.54 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.69
|
| Rate for Payer: Cash Price |
$2.37
|
| Rate for Payer: Cigna Commercial |
$3.93
|
| Rate for Payer: First Health Commercial |
$4.49
|
| Rate for Payer: Humana Commercial |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.16
|
| Rate for Payer: Ohio Health Group HMO |
$3.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.47
|
| Rate for Payer: PHCS Commercial |
$4.54
|
| Rate for Payer: United Healthcare All Payer |
$4.16
|
|
|
SEROQUEL (QUETIAP FUM)25MGTAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 60687032701
|
| Hospital Charge Code |
25001386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
SEROQUEL (QUETIAP FUM)25MGTAB
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 60687032701
|
| Hospital Charge Code |
25001386
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.35 |
| Rate for Payer: Aetna Commercial |
$3.49
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.76
|
| Rate for Payer: First Health Commercial |
$4.30
|
| Rate for Payer: Humana Commercial |
$3.85
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.99
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.35
|
| Rate for Payer: United Healthcare All Payer |
$3.99
|
|
|
SEROSAFUSE IMP FASTENER CART 7
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
SEROSAFUSE IMP FASTENER CART 7
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem Medicaid |
$1,358.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Humana KY Medicaid |
$1,358.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,372.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
SERZONE 50MG TABLET
|
Facility
|
OP
|
$9.30
|
|
|
Service Code
|
NDC 93717801
|
| Hospital Charge Code |
25001393
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Anthem Medicaid |
$3.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: First Health Commercial |
$8.84
|
| Rate for Payer: Humana Commercial |
$7.90
|
| Rate for Payer: Humana KY Medicaid |
$3.20
|
| Rate for Payer: Kentucky WC Medicaid |
$3.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$8.93
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
SERZONE 50MG TABLET
|
Facility
|
IP
|
$9.30
|
|
|
Service Code
|
NDC 93717801
|
| Hospital Charge Code |
25001393
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.93 |
| Rate for Payer: Aetna Commercial |
$7.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.25
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cigna Commercial |
$7.72
|
| Rate for Payer: First Health Commercial |
$8.84
|
| Rate for Payer: Humana Commercial |
$7.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.18
|
| Rate for Payer: Ohio Health Group HMO |
$6.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.88
|
| Rate for Payer: PHCS Commercial |
$8.93
|
| Rate for Payer: United Healthcare All Payer |
$8.18
|
|
|
SERZONE (NEFAZODONE 100MG/1TAB
|
Facility
|
IP
|
$9.37
|
|
|
Service Code
|
NDC 93102406
|
| Hospital Charge Code |
25001392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.78
|
| Rate for Payer: First Health Commercial |
$8.90
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.25
|
| Rate for Payer: Ohio Health Group HMO |
$7.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Payer |
$8.25
|
|
|
SERZONE (NEFAZODONE 100MG/1TAB
|
Facility
|
OP
|
$9.37
|
|
|
Service Code
|
NDC 93102406
|
| Hospital Charge Code |
25001392
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Aetna Commercial |
$7.21
|
| Rate for Payer: Anthem Medicaid |
$3.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.31
|
| Rate for Payer: Cash Price |
$4.68
|
| Rate for Payer: Cigna Commercial |
$7.78
|
| Rate for Payer: First Health Commercial |
$8.90
|
| Rate for Payer: Humana Commercial |
$7.96
|
| Rate for Payer: Humana KY Medicaid |
$3.22
|
| Rate for Payer: Kentucky WC Medicaid |
$3.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.25
|
| Rate for Payer: Ohio Health Group HMO |
$7.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$9.00
|
| Rate for Payer: United Healthcare All Payer |
$8.25
|
|
|
SESAME SEED IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000780
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SESAME SEED IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000780
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SET INTRODUCER 12FR
|
Facility
|
IP
|
$1,893.10
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$246.10 |
| Max. Negotiated Rate |
$1,817.38 |
| Rate for Payer: Aetna Commercial |
$1,457.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.62
|
| Rate for Payer: Cash Price |
$946.55
|
| Rate for Payer: Cigna Commercial |
$1,571.27
|
| Rate for Payer: First Health Commercial |
$1,798.44
|
| Rate for Payer: Humana Commercial |
$1,609.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,552.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,397.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.93
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.86
|
| Rate for Payer: PHCS Commercial |
$1,817.38
|
| Rate for Payer: United Healthcare All Payer |
$1,665.93
|
|
|
SET INTRODUCER 12FR
|
Facility
|
OP
|
$1,893.10
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$246.10 |
| Max. Negotiated Rate |
$1,817.38 |
| Rate for Payer: Aetna Commercial |
$1,457.69
|
| Rate for Payer: Anthem Medicaid |
$651.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.62
|
| Rate for Payer: Cash Price |
$946.55
|
| Rate for Payer: Cigna Commercial |
$1,571.27
|
| Rate for Payer: First Health Commercial |
$1,798.44
|
| Rate for Payer: Humana Commercial |
$1,609.14
|
| Rate for Payer: Humana KY Medicaid |
$651.04
|
| Rate for Payer: Kentucky WC Medicaid |
$657.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,552.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,397.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$664.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.93
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$378.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$586.86
|
| Rate for Payer: PHCS Commercial |
$1,817.38
|
| Rate for Payer: United Healthcare All Payer |
$1,665.93
|
|
