|
SINEQUAN (DOXEPIN) 2 25MG/1CAP
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 27241016801
|
| Hospital Charge Code |
25001404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
SINEQUAN (DOXEPIN) 2 25MG/1CAP
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 27241016801
|
| Hospital Charge Code |
25001404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| 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 |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
SINGLE CHAMBER PACE MAKER
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
76101242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$417.13 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$783.12
|
| Rate for Payer: Anthem Medicaid |
$417.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$731.76
|
| Rate for Payer: Healthspan PPO |
$769.96
|
| Rate for Payer: Humana Medicaid |
$417.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$644.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$425.47
|
| Rate for Payer: Molina Healthcare Passport |
$417.13
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$421.30
|
|
|
SINGLE CHAMBER PACE MAKER
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
76101242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$12,927.70 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,234.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,927.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,465.99
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$9,234.07
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,080.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
SINGLE CHAMBER PACE MAKER
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
76101242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
SINGLE CHAMBER PACE MAKER(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33206
|
| Hospital Charge Code |
761P1242
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$417.13 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$783.12
|
| Rate for Payer: Anthem Medicaid |
$417.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$731.76
|
| Rate for Payer: Healthspan PPO |
$769.96
|
| Rate for Payer: Humana Medicaid |
$417.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$644.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$425.47
|
| Rate for Payer: Molina Healthcare Passport |
$417.13
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$421.30
|
|
|
SINGULAIR 4 MG CHEW TAB
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 31722072730
|
| Hospital Charge Code |
25001405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| 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 |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
SINGULAIR 4 MG CHEW TAB
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 31722072730
|
| Hospital Charge Code |
25001405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| 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 |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
SINGULAIR 4MG GRANULES
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 27241001531
|
| Hospital Charge Code |
25001406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
SINGULAIR 4MG GRANULES
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 27241001531
|
| Hospital Charge Code |
25001406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
SINGULAR (MONTELUKAST)10MG TAB
|
Facility
|
IP
|
$4.53
|
|
|
Service Code
|
NDC 904680861
|
| Hospital Charge Code |
25001408
|
|
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
|
|
|
SINGULAR (MONTELUKAST)10MG TAB
|
Facility
|
OP
|
$4.53
|
|
|
Service Code
|
NDC 904680861
|
| Hospital Charge Code |
25001408
|
|
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
|
|
|
SINGULAR (MONTELUKAST) 5MG TAB
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 57237021390
|
| Hospital Charge Code |
25001407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SINGULAR (MONTELUKAST) 5MG TAB
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 57237021390
|
| Hospital Charge Code |
25001407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.13 |
| Rate for Payer: Aetna Commercial |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.57
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.13
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
SINUS AND MASTOID PROCEDURES WITH CC/MCC
|
Facility
|
IP
|
$31,024.80
|
|
|
Service Code
|
MSDRG 135
|
| Min. Negotiated Rate |
$21,052.54 |
| Max. Negotiated Rate |
$31,024.80 |
| Rate for Payer: Anthem Medicaid |
$21,052.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22,160.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31,024.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$29,916.77
|
| Rate for Payer: Humana KY Medicaid |
$21,052.54
|
| Rate for Payer: Humana Medicare Advantage |
$22,160.57
|
| Rate for Payer: Kentucky WC Medicaid |
$21,263.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26,592.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$21,473.59
|
|
|
SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC
|
Facility
|
IP
|
$12,216.43
|
|
|
Service Code
|
MSDRG 136
|
| Min. Negotiated Rate |
$8,289.72 |
| Max. Negotiated Rate |
$12,216.43 |
| Rate for Payer: Anthem Medicaid |
$8,289.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,726.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,216.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,780.13
|
| Rate for Payer: Humana KY Medicaid |
$8,289.72
|
| Rate for Payer: Humana Medicare Advantage |
$8,726.02
|
| Rate for Payer: Kentucky WC Medicaid |
$8,372.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,471.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,455.51
|
|
|
SINUS ENDO
|
Professional
|
Both
|
$970.00
|
|
|
Service Code
|
HCPCS 31256
|
| Hospital Charge Code |
76101155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.62 |
| Max. Negotiated Rate |
$970.00 |
| Rate for Payer: Aetna Commercial |
$304.41
|
| Rate for Payer: Anthem Medicaid |
$207.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$970.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$307.15
|
| Rate for Payer: Healthspan PPO |
$256.72
|
| Rate for Payer: Humana Medicaid |
$207.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$258.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$211.77
|
| Rate for Payer: Molina Healthcare Passport |
$207.62
|
| Rate for Payer: Multiplan PHCS |
$582.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$679.00
|
| Rate for Payer: UHCCP Medicaid |
$339.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$209.70
|
|
|
SINUS ENDO
|
Facility
|
IP
|
$970.00
|
|
|
Service Code
|
HCPCS 31256
|
| Hospital Charge Code |
76101155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.10 |
| Max. Negotiated Rate |
$931.20 |
| Rate for Payer: Aetna Commercial |
$746.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$756.60
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$805.10
|
| Rate for Payer: First Health Commercial |
$921.50
|
| Rate for Payer: Humana Commercial |
$824.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$795.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$715.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$853.60
|
| Rate for Payer: Ohio Health Group HMO |
$727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$194.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.70
|
| Rate for Payer: PHCS Commercial |
$931.20
|
| Rate for Payer: United Healthcare All Payer |
$853.60
|
|
|
SINUS ENDO
|
Facility
|
OP
|
$970.00
|
|
|
Service Code
|
HCPCS 31256
|
| Hospital Charge Code |
76101155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$126.10 |
| Max. Negotiated Rate |
$4,533.70 |
| Rate for Payer: Aetna Commercial |
$746.90
|
| Rate for Payer: Anthem Medicaid |
$333.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,238.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$756.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,533.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,371.79
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$805.10
|
| Rate for Payer: First Health Commercial |
$921.50
|
| Rate for Payer: Humana Commercial |
$824.50
|
| Rate for Payer: Humana KY Medicaid |
$333.58
|
| Rate for Payer: Humana Medicare Advantage |
$3,238.36
|
| Rate for Payer: Kentucky WC Medicaid |
$336.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$795.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$715.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,886.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$340.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$853.60
|
| Rate for Payer: Ohio Health Group HMO |
$727.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$194.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$300.70
|
| Rate for Payer: PHCS Commercial |
$931.20
|
| Rate for Payer: United Healthcare All Payer |
$853.60
|
|
|
SINUS ENDO(P
|
Professional
|
Both
|
$970.00
|
|
|
Service Code
|
HCPCS 31256
|
| Hospital Charge Code |
761P1155
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$207.62 |
| Max. Negotiated Rate |
$970.00 |
| Rate for Payer: Aetna Commercial |
$304.41
|
| Rate for Payer: Anthem Medicaid |
$207.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$970.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cash Price |
$485.00
|
| Rate for Payer: Cigna Commercial |
$307.15
|
| Rate for Payer: Healthspan PPO |
$256.72
|
| Rate for Payer: Humana Medicaid |
$207.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$258.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$211.77
|
| Rate for Payer: Molina Healthcare Passport |
$207.62
|
| Rate for Payer: Multiplan PHCS |
$582.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$679.00
|
| Rate for Payer: UHCCP Medicaid |
$339.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$209.70
|
|
|
SINUS ENDO W/BALLOON DIL
|
Facility
|
IP
|
$2,845.00
|
|
|
Service Code
|
HCPCS 31295
|
| Hospital Charge Code |
76101159
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.85 |
| Max. Negotiated Rate |
$2,731.20 |
| Rate for Payer: Aetna Commercial |
$2,190.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,219.10
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$2,361.35
|
| Rate for Payer: First Health Commercial |
$2,702.75
|
| Rate for Payer: Humana Commercial |
$2,418.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,332.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,099.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$853.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,503.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,133.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$881.95
|
| Rate for Payer: PHCS Commercial |
$2,731.20
|
| Rate for Payer: United Healthcare All Payer |
$2,503.60
|
|
|
SINUS ENDO W/BALLOON DIL
|
Professional
|
Both
|
$2,845.00
|
|
|
Service Code
|
HCPCS 31295
|
| Hospital Charge Code |
76101159
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.42 |
| Max. Negotiated Rate |
$3,087.02 |
| Rate for Payer: Aetna Commercial |
$280.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$84.42
|
| Rate for Payer: Anthem Medicaid |
$125.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,845.00
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$3,087.02
|
| Rate for Payer: Healthspan PPO |
$1,997.11
|
| Rate for Payer: Humana Medicaid |
$125.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$223.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$128.06
|
| Rate for Payer: Molina Healthcare Passport |
$125.55
|
| Rate for Payer: Multiplan PHCS |
$1,707.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,991.50
|
| Rate for Payer: UHCCP Medicaid |
$88.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$126.81
|
|
|
SINUS ENDO W/BALLOON DIL
|
Facility
|
OP
|
$2,845.00
|
|
|
Service Code
|
HCPCS 31295
|
| Hospital Charge Code |
76101159
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.85 |
| Max. Negotiated Rate |
$8,286.08 |
| Rate for Payer: Aetna Commercial |
$2,190.65
|
| Rate for Payer: Anthem Medicaid |
$978.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,918.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,219.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,286.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,990.15
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$2,361.35
|
| Rate for Payer: First Health Commercial |
$2,702.75
|
| Rate for Payer: Humana Commercial |
$2,418.25
|
| Rate for Payer: Humana KY Medicaid |
$978.40
|
| Rate for Payer: Humana Medicare Advantage |
$5,918.63
|
| Rate for Payer: Kentucky WC Medicaid |
$988.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,332.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,099.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,102.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$998.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,503.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,133.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$881.95
|
| Rate for Payer: PHCS Commercial |
$2,731.20
|
| Rate for Payer: United Healthcare All Payer |
$2,503.60
|
|
|
SINUS ENDO W/BALLOON DIL(P
|
Professional
|
Both
|
$2,845.00
|
|
|
Service Code
|
HCPCS 31295
|
| Hospital Charge Code |
761P1159
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.42 |
| Max. Negotiated Rate |
$3,087.02 |
| Rate for Payer: Aetna Commercial |
$280.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$84.42
|
| Rate for Payer: Anthem Medicaid |
$125.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,845.00
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cash Price |
$1,422.50
|
| Rate for Payer: Cigna Commercial |
$3,087.02
|
| Rate for Payer: Healthspan PPO |
$1,997.11
|
| Rate for Payer: Humana Medicaid |
$125.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$223.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$128.06
|
| Rate for Payer: Molina Healthcare Passport |
$125.55
|
| Rate for Payer: Multiplan PHCS |
$1,707.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,991.50
|
| Rate for Payer: UHCCP Medicaid |
$88.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$126.81
|
|
|
SINUSOTOMY
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 31030
|
| Hospital Charge Code |
76101145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.57 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$737.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$264.57
|
| Rate for Payer: Anthem Medicaid |
$377.27
|
| 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 |
$727.34
|
| Rate for Payer: Healthspan PPO |
$808.65
|
| Rate for Payer: Humana Medicaid |
$377.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$655.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.82
|
| Rate for Payer: Molina Healthcare Passport |
$377.27
|
| 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 |
$277.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.04
|
|
