|
SELF CENT HIP COMP 61MM 28MM
|
Facility
|
IP
|
$4,705.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,411.69 |
| Max. Negotiated Rate |
$4,517.40 |
| Rate for Payer: Aetna Commercial |
$3,623.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,670.38
|
| Rate for Payer: Cash Price |
$2,352.81
|
| Rate for Payer: Cigna Commercial |
$3,905.66
|
| Rate for Payer: First Health Commercial |
$4,470.34
|
| Rate for Payer: Humana Commercial |
$3,999.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,858.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,472.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,411.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,140.95
|
| Rate for Payer: Ohio Health Group HMO |
$3,529.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,764.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,093.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,246.88
|
| Rate for Payer: PHCS Commercial |
$4,517.40
|
| Rate for Payer: United Healthcare All Payer |
$4,140.95
|
|
|
SELF CENT HIP COMP 63MM 28MM
|
Facility
|
OP
|
$7,615.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.78 |
| Max. Negotiated Rate |
$7,311.30 |
| Rate for Payer: Aetna Commercial |
$5,864.27
|
| Rate for Payer: Anthem Medicaid |
$2,619.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,940.43
|
| Rate for Payer: Cash Price |
$3,807.97
|
| Rate for Payer: Cigna Commercial |
$6,321.23
|
| Rate for Payer: First Health Commercial |
$7,235.14
|
| Rate for Payer: Humana Commercial |
$6,473.55
|
| Rate for Payer: Humana KY Medicaid |
$2,619.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,645.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,245.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,620.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,671.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,702.03
|
| Rate for Payer: Ohio Health Group HMO |
$5,711.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,092.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,625.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,255.00
|
| Rate for Payer: PHCS Commercial |
$7,311.30
|
| Rate for Payer: United Healthcare All Payer |
$6,702.03
|
|
|
SELF CENT HIP COMP 63MM 28MM
|
Facility
|
IP
|
$7,615.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.78 |
| Max. Negotiated Rate |
$7,311.30 |
| Rate for Payer: Aetna Commercial |
$5,864.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,940.43
|
| Rate for Payer: Cash Price |
$3,807.97
|
| Rate for Payer: Cigna Commercial |
$6,321.23
|
| Rate for Payer: First Health Commercial |
$7,235.14
|
| Rate for Payer: Humana Commercial |
$6,473.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,245.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,620.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,702.03
|
| Rate for Payer: Ohio Health Group HMO |
$5,711.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,092.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,625.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,255.00
|
| Rate for Payer: PHCS Commercial |
$7,311.30
|
| Rate for Payer: United Healthcare All Payer |
$6,702.03
|
|
|
SELF CENT HIP COMP 65MM 28MM
|
Facility
|
IP
|
$7,799.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,339.93 |
| Max. Negotiated Rate |
$7,487.76 |
| Rate for Payer: Aetna Commercial |
$6,005.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,083.81
|
| Rate for Payer: Cash Price |
$3,899.88
|
| Rate for Payer: Cigna Commercial |
$6,473.79
|
| Rate for Payer: First Health Commercial |
$7,409.76
|
| Rate for Payer: Humana Commercial |
$6,629.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,395.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,756.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,339.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,863.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,849.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,239.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,785.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,381.83
|
| Rate for Payer: PHCS Commercial |
$7,487.76
|
| Rate for Payer: United Healthcare All Payer |
$6,863.78
|
|
|
SELF CENT HIP COMP 65MM 28MM
|
Facility
|
OP
|
$7,799.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,339.93 |
| Max. Negotiated Rate |
$7,487.76 |
| Rate for Payer: Aetna Commercial |
$6,005.81
|
| Rate for Payer: Anthem Medicaid |
$2,682.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,083.81
|
| Rate for Payer: Cash Price |
$3,899.88
|
| Rate for Payer: Cigna Commercial |
$6,473.79
|
| Rate for Payer: First Health Commercial |
$7,409.76
|
| Rate for Payer: Humana Commercial |
$6,629.79
|
| Rate for Payer: Humana KY Medicaid |
$2,682.33
|
| Rate for Payer: Kentucky WC Medicaid |
$2,709.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,395.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,756.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,339.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,736.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,863.78
|
| Rate for Payer: Ohio Health Group HMO |
$5,849.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,239.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,785.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,381.83
|
| Rate for Payer: PHCS Commercial |
$7,487.76
|
| Rate for Payer: United Healthcare All Payer |
$6,863.78
|
|
|
SELF PAY CT SCREEN COR ART
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
35000090
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$90.00 |
| 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 |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
SELF PAY CT SCREEN COR ART
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
35000090
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$103.17 |
| Max. Negotiated Rate |
$461.97 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem Medicaid |
$103.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| 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 |
$329.98
|
| 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 |
$395.98
|
| 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 |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| 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
|
$311.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
350T0090
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$93.30 |
| Max. Negotiated Rate |
$298.56 |
| Rate for Payer: Aetna Commercial |
$239.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$242.58
|
| Rate for Payer: Cash Price |
$155.50
|
| Rate for Payer: Cigna Commercial |
$258.13
|
| Rate for Payer: First Health Commercial |
$295.45
|
| Rate for Payer: Humana Commercial |
$264.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$255.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$229.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$93.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$273.68
|
| Rate for Payer: Ohio Health Group HMO |
$233.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$248.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$270.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$214.59
|
| Rate for Payer: PHCS Commercial |
$298.56
|
| Rate for Payer: United Healthcare All Payer |
$273.68
|
|
|
SELF PAY CT SCREEN COR ART(T
|
Facility
|
OP
|
$311.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
350T0090
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$106.95 |
| Max. Negotiated Rate |
$461.97 |
| Rate for Payer: Aetna Commercial |
$239.47
|
| Rate for Payer: Anthem Medicaid |
$106.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$329.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$242.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$461.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$445.47
|
| Rate for Payer: Cash Price |
$155.50
|
| Rate for Payer: Cash Price |
$155.50
|
| Rate for Payer: Cigna Commercial |
$258.13
|
| Rate for Payer: First Health Commercial |
$295.45
|
| Rate for Payer: Humana Commercial |
$264.35
|
| Rate for Payer: Humana KY Medicaid |
$106.95
|
| Rate for Payer: Humana Medicare Advantage |
$329.98
|
| Rate for Payer: Kentucky WC Medicaid |
$108.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$255.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$229.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$395.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$109.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$273.68
|
| Rate for Payer: Ohio Health Group HMO |
$233.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$248.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$270.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$214.59
|
| Rate for Payer: PHCS Commercial |
$298.56
|
| Rate for Payer: United Healthcare All Payer |
$273.68
|
|
|
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 |
$192.90 |
| 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 |
$514.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$443.67
|
| Rate for Payer: PHCS Commercial |
$617.28
|
| Rate for Payer: United Healthcare All Payer |
$565.84
|
|
|
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 |
$125.40 |
| 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 |
$334.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$363.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.42
|
| Rate for Payer: PHCS Commercial |
$401.28
|
| Rate for Payer: United Healthcare All Payer |
$367.84
|
|
|
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 |
$125.40 |
| 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 |
$334.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$363.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.42
|
| Rate for Payer: PHCS Commercial |
$401.28
|
| Rate for Payer: United Healthcare All Payer |
$367.84
|
|
|
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 |
$385.80 |
| Rate for Payer: Ambetter Exchange |
$115.84
|
| Rate for Payer: Anthem Medicaid |
$103.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$115.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$139.01
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$115.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$115.84
|
| 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 |
$150.59
|
| Rate for Payer: UHCCP Medicaid |
$225.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$115.84
|
|
|
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 |
$192.90 |
| 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 |
$514.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$443.67
|
| Rate for Payer: PHCS Commercial |
$617.28
|
| Rate for Payer: United Healthcare All Payer |
$565.84
|
|
|
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 |
$214.76 |
| Rate for Payer: Ambetter Exchange |
$115.84
|
| Rate for Payer: Anthem Medicaid |
$103.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$115.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$139.01
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$115.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$115.84
|
| 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 |
$150.59
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$104.36
|
| Rate for Payer: Wellcare Medicare Advantage |
$115.84
|
|
|
SELF RETAINING DRIVER
|
Facility
|
IP
|
$3,406.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.88 |
| Max. Negotiated Rate |
$3,270.00 |
| Rate for Payer: Aetna Commercial |
$2,622.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,656.88
|
| Rate for Payer: Cash Price |
$1,703.12
|
| Rate for Payer: Cigna Commercial |
$2,827.19
|
| Rate for Payer: First Health Commercial |
$3,235.94
|
| Rate for Payer: Humana Commercial |
$2,895.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,793.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,513.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,021.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,997.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,554.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,725.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,963.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,350.31
|
| Rate for Payer: PHCS Commercial |
$3,270.00
|
| Rate for Payer: United Healthcare All Payer |
$2,997.50
|
|
|
SELF RETAINING DRIVER
|
Facility
|
OP
|
$3,406.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.88 |
| Max. Negotiated Rate |
$3,270.00 |
| Rate for Payer: Aetna Commercial |
$2,622.81
|
| Rate for Payer: Anthem Medicaid |
$1,171.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,656.88
|
| Rate for Payer: Cash Price |
$1,703.12
|
| Rate for Payer: Cigna Commercial |
$2,827.19
|
| Rate for Payer: First Health Commercial |
$3,235.94
|
| Rate for Payer: Humana Commercial |
$2,895.31
|
| Rate for Payer: Humana KY Medicaid |
$1,171.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,183.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,793.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,513.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,021.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,194.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,997.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,554.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,725.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,963.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,350.31
|
| Rate for Payer: PHCS Commercial |
$3,270.00
|
| Rate for Payer: United Healthcare All Payer |
$2,997.50
|
|
|
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 |
$2.55 |
| 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 |
$6.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.86
|
| Rate for Payer: PHCS Commercial |
$8.15
|
| Rate for Payer: United Healthcare All Payer |
$7.47
|
|
|
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 |
$2.55 |
| 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 |
$6.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5.86
|
| Rate for Payer: PHCS Commercial |
$8.15
|
| Rate for Payer: United Healthcare All Payer |
$7.47
|
|
|
SEMITENDINOSUS IRRADIATED
|
Facility
|
IP
|
$9,077.25
|
|
|
Service Code
|
HCPCS C9356
|
| Hospital Charge Code |
27000132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,723.18 |
| Max. Negotiated Rate |
$8,714.16 |
| Rate for Payer: Aetna Commercial |
$6,989.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,080.26
|
| Rate for Payer: Cash Price |
$4,538.62
|
| Rate for Payer: Cigna Commercial |
$7,534.12
|
| Rate for Payer: First Health Commercial |
$8,623.39
|
| Rate for Payer: Humana Commercial |
$7,715.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,443.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,699.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,723.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,987.98
|
| Rate for Payer: Ohio Health Group HMO |
$6,807.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,261.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,897.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,263.30
|
| Rate for Payer: PHCS Commercial |
$8,714.16
|
| Rate for Payer: United Healthcare All Payer |
$7,987.98
|
|
|
SEMITENDINOSUS IRRADIATED
|
Facility
|
OP
|
$9,077.25
|
|
|
Service Code
|
HCPCS C9356
|
| Hospital Charge Code |
27000132
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,723.18 |
| Max. Negotiated Rate |
$8,714.16 |
| Rate for Payer: Aetna Commercial |
$6,989.48
|
| Rate for Payer: Anthem Medicaid |
$3,121.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,080.26
|
| Rate for Payer: Cash Price |
$4,538.62
|
| Rate for Payer: Cigna Commercial |
$7,534.12
|
| Rate for Payer: First Health Commercial |
$8,623.39
|
| Rate for Payer: Humana Commercial |
$7,715.66
|
| Rate for Payer: Humana KY Medicaid |
$3,121.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3,153.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,443.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,699.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,723.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,184.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,987.98
|
| Rate for Payer: Ohio Health Group HMO |
$6,807.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,261.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,897.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,263.30
|
| Rate for Payer: PHCS Commercial |
$8,714.16
|
| Rate for Payer: United Healthcare All Payer |
$7,987.98
|
|
|
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 |
$1.27 |
| 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 |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
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 |
$1.27 |
| 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 |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| 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 |
$1.27 |
| 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 |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| 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 |
$1.27 |
| 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 |
$3.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
