|
SOMATOSENSORY TESTING(T
|
Facility
|
OP
|
$1,010.00
|
|
|
Service Code
|
HCPCS 95925
|
| Hospital Charge Code |
510T0039
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$131.30 |
| Max. Negotiated Rate |
$969.60 |
| Rate for Payer: Aetna Commercial |
$777.70
|
| Rate for Payer: Anthem Medicaid |
$347.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$271.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$787.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$380.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$366.43
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cash Price |
$505.00
|
| Rate for Payer: Cigna Commercial |
$838.30
|
| Rate for Payer: First Health Commercial |
$959.50
|
| Rate for Payer: Humana Commercial |
$858.50
|
| Rate for Payer: Humana KY Medicaid |
$347.34
|
| Rate for Payer: Humana Medicare Advantage |
$271.43
|
| Rate for Payer: Kentucky WC Medicaid |
$350.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$828.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$745.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$354.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$888.80
|
| Rate for Payer: Ohio Health Group HMO |
$757.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$202.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$313.10
|
| Rate for Payer: PHCS Commercial |
$969.60
|
| Rate for Payer: United Healthcare All Payer |
$888.80
|
|
|
SOMATROPIN 1mg (6mg SDV)
|
Facility
|
OP
|
$1,872.60
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$148.44 |
| Max. Negotiated Rate |
$1,797.70 |
| Rate for Payer: Aetna Commercial |
$1,441.90
|
| Rate for Payer: Anthem Medicaid |
$643.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$148.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,460.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$207.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$200.39
|
| Rate for Payer: Cash Price |
$936.30
|
| Rate for Payer: Cash Price |
$936.30
|
| Rate for Payer: Cigna Commercial |
$1,554.26
|
| Rate for Payer: First Health Commercial |
$1,778.97
|
| Rate for Payer: Humana Commercial |
$1,591.71
|
| Rate for Payer: Humana KY Medicaid |
$643.99
|
| Rate for Payer: Humana Medicare Advantage |
$148.44
|
| Rate for Payer: Kentucky WC Medicaid |
$650.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,535.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,647.89
|
| Rate for Payer: Ohio Health Group HMO |
$1,404.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.51
|
| Rate for Payer: PHCS Commercial |
$1,797.70
|
| Rate for Payer: United Healthcare All Payer |
$1,647.89
|
|
|
SOMATROPIN 1mg (6mg SDV)
|
Facility
|
IP
|
$1,872.60
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002368
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$243.44 |
| Max. Negotiated Rate |
$1,797.70 |
| Rate for Payer: Aetna Commercial |
$1,441.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,460.63
|
| Rate for Payer: Cash Price |
$936.30
|
| Rate for Payer: Cigna Commercial |
$1,554.26
|
| Rate for Payer: First Health Commercial |
$1,778.97
|
| Rate for Payer: Humana Commercial |
$1,591.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,535.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,381.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,647.89
|
| Rate for Payer: Ohio Health Group HMO |
$1,404.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$374.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$580.51
|
| Rate for Payer: PHCS Commercial |
$1,797.70
|
| Rate for Payer: United Healthcare All Payer |
$1,647.89
|
|
|
SOMATULINE DEPOT 1mg(120mg)PFS
|
Facility
|
IP
|
$52,112.90
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,774.68 |
| Max. Negotiated Rate |
$50,028.38 |
| Rate for Payer: Aetna Commercial |
$40,126.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40,648.06
|
| Rate for Payer: Cash Price |
$26,056.45
|
| Rate for Payer: Cigna Commercial |
$43,253.71
|
| Rate for Payer: First Health Commercial |
$49,507.26
|
| Rate for Payer: Humana Commercial |
$44,295.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42,732.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38,459.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15,633.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$45,859.35
|
| Rate for Payer: Ohio Health Group HMO |
$39,084.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,422.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,774.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,155.00
|
| Rate for Payer: PHCS Commercial |
$50,028.38
|
| Rate for Payer: United Healthcare All Payer |
$45,859.35
|
|
|
SOMATULINE DEPOT 1mg(120mg)PFS
|
Facility
|
OP
|
$52,112.90
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004152
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$50,028.38 |
| Rate for Payer: Aetna Commercial |
$40,126.93
|
| Rate for Payer: Anthem Medicaid |
$17,921.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40,648.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.40
|
| Rate for Payer: Cash Price |
$26,056.45
|
| Rate for Payer: Cash Price |
$26,056.45
|
| Rate for Payer: Cigna Commercial |
$43,253.71
|
| Rate for Payer: First Health Commercial |
$49,507.26
|
| Rate for Payer: Humana Commercial |
$44,295.96
|
| Rate for Payer: Humana KY Medicaid |
$17,921.63
|
| Rate for Payer: Humana Medicare Advantage |
$48.44
|
| Rate for Payer: Kentucky WC Medicaid |
$18,104.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42,732.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38,459.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$18,281.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$45,859.35
|
| Rate for Payer: Ohio Health Group HMO |
$39,084.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,422.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,774.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,155.00
|
| Rate for Payer: PHCS Commercial |
$50,028.38
|
| Rate for Payer: United Healthcare All Payer |
$45,859.35
|
|
|
SOMATULINE DEPOT 1mg (60mg)PFS
|
Facility
|
IP
|
$33,179.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,313.35 |
| Max. Negotiated Rate |
$31,852.42 |
| Rate for Payer: Aetna Commercial |
$25,548.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,880.09
|
| Rate for Payer: Cash Price |
$16,589.80
|
| Rate for Payer: Cigna Commercial |
$27,539.07
|
| Rate for Payer: First Health Commercial |
$31,520.62
|
| Rate for Payer: Humana Commercial |
$28,202.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,207.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,486.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,953.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,198.05
|
| Rate for Payer: Ohio Health Group HMO |
$24,884.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,635.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,313.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,285.68
|
| Rate for Payer: PHCS Commercial |
$31,852.42
|
| Rate for Payer: United Healthcare All Payer |
$29,198.05
|
|
|
SOMATULINE DEPOT 1mg (60mg)PFS
|
Facility
|
OP
|
$33,179.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004150
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$31,852.42 |
| Rate for Payer: Aetna Commercial |
$25,548.29
|
| Rate for Payer: Anthem Medicaid |
$11,410.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,880.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.40
|
| Rate for Payer: Cash Price |
$16,589.80
|
| Rate for Payer: Cash Price |
$16,589.80
|
| Rate for Payer: Cigna Commercial |
$27,539.07
|
| Rate for Payer: First Health Commercial |
$31,520.62
|
| Rate for Payer: Humana Commercial |
$28,202.66
|
| Rate for Payer: Humana KY Medicaid |
$11,410.46
|
| Rate for Payer: Humana Medicare Advantage |
$48.44
|
| Rate for Payer: Kentucky WC Medicaid |
$11,526.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,207.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,486.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,639.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,198.05
|
| Rate for Payer: Ohio Health Group HMO |
$24,884.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,635.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,313.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,285.68
|
| Rate for Payer: PHCS Commercial |
$31,852.42
|
| Rate for Payer: United Healthcare All Payer |
$29,198.05
|
|
|
SOMATULINE DEPOT 1mg (90mg)PFS
|
Facility
|
OP
|
$44,188.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.44 |
| Max. Negotiated Rate |
$42,421.06 |
| Rate for Payer: Aetna Commercial |
$34,025.22
|
| Rate for Payer: Anthem Medicaid |
$15,196.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,467.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$67.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$65.40
|
| Rate for Payer: Cash Price |
$22,094.30
|
| Rate for Payer: Cash Price |
$22,094.30
|
| Rate for Payer: Cigna Commercial |
$36,676.54
|
| Rate for Payer: First Health Commercial |
$41,979.17
|
| Rate for Payer: Humana Commercial |
$37,560.31
|
| Rate for Payer: Humana KY Medicaid |
$15,196.46
|
| Rate for Payer: Humana Medicare Advantage |
$48.44
|
| Rate for Payer: Kentucky WC Medicaid |
$15,351.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,234.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,611.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,501.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,885.97
|
| Rate for Payer: Ohio Health Group HMO |
$33,141.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,837.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,744.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,698.47
|
| Rate for Payer: PHCS Commercial |
$42,421.06
|
| Rate for Payer: United Healthcare All Payer |
$38,885.97
|
|
|
SOMATULINE DEPOT 1mg (90mg)PFS
|
Facility
|
IP
|
$44,188.60
|
|
|
Service Code
|
HCPCS J1930
|
| Hospital Charge Code |
25004151
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,744.52 |
| Max. Negotiated Rate |
$42,421.06 |
| Rate for Payer: Aetna Commercial |
$34,025.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,467.11
|
| Rate for Payer: Cash Price |
$22,094.30
|
| Rate for Payer: Cigna Commercial |
$36,676.54
|
| Rate for Payer: First Health Commercial |
$41,979.17
|
| Rate for Payer: Humana Commercial |
$37,560.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,234.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,611.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,256.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,885.97
|
| Rate for Payer: Ohio Health Group HMO |
$33,141.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,837.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,744.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,698.47
|
| Rate for Payer: PHCS Commercial |
$42,421.06
|
| Rate for Payer: United Healthcare All Payer |
$38,885.97
|
|
|
SON 2 CATH 5F
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SON 2 CATH 5F
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1886
|
| Hospital Charge Code |
27000013
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SONICANCHOR 2.5X10 FIBER 0
|
Facility
|
IP
|
$4,028.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.72 |
| Max. Negotiated Rate |
$3,867.49 |
| Rate for Payer: Aetna Commercial |
$3,102.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.34
|
| Rate for Payer: Cash Price |
$2,014.32
|
| Rate for Payer: Cigna Commercial |
$3,343.77
|
| Rate for Payer: First Health Commercial |
$3,827.21
|
| Rate for Payer: Humana Commercial |
$3,424.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.88
|
| Rate for Payer: PHCS Commercial |
$3,867.49
|
| Rate for Payer: United Healthcare All Payer |
$3,545.20
|
|
|
SONICANCHOR 2.5X10 FIBER 0
|
Facility
|
OP
|
$4,028.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.72 |
| Max. Negotiated Rate |
$3,867.49 |
| Rate for Payer: Aetna Commercial |
$3,102.05
|
| Rate for Payer: Anthem Medicaid |
$1,385.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.34
|
| Rate for Payer: Cash Price |
$2,014.32
|
| Rate for Payer: Cigna Commercial |
$3,343.77
|
| Rate for Payer: First Health Commercial |
$3,827.21
|
| Rate for Payer: Humana Commercial |
$3,424.34
|
| Rate for Payer: Humana KY Medicaid |
$1,385.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,399.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,413.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.88
|
| Rate for Payer: PHCS Commercial |
$3,867.49
|
| Rate for Payer: United Healthcare All Payer |
$3,545.20
|
|
|
SONICANCHOR 2.5X10 FIBER 2
|
Facility
|
OP
|
$4,028.64
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.72 |
| Max. Negotiated Rate |
$3,867.49 |
| Rate for Payer: Aetna Commercial |
$3,102.05
|
| Rate for Payer: Anthem Medicaid |
$1,385.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.34
|
| Rate for Payer: Cash Price |
$2,014.32
|
| Rate for Payer: Cigna Commercial |
$3,343.77
|
| Rate for Payer: First Health Commercial |
$3,827.21
|
| Rate for Payer: Humana Commercial |
$3,424.34
|
| Rate for Payer: Humana KY Medicaid |
$1,385.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,399.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,413.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.88
|
| Rate for Payer: PHCS Commercial |
$3,867.49
|
| Rate for Payer: United Healthcare All Payer |
$3,545.20
|
|
|
SONICANCHOR 2.5X10 FIBER 2
|
Facility
|
IP
|
$4,028.64
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.72 |
| Max. Negotiated Rate |
$3,867.49 |
| Rate for Payer: Aetna Commercial |
$3,102.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.34
|
| Rate for Payer: Cash Price |
$2,014.32
|
| Rate for Payer: Cigna Commercial |
$3,343.77
|
| Rate for Payer: First Health Commercial |
$3,827.21
|
| Rate for Payer: Humana Commercial |
$3,424.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.88
|
| Rate for Payer: PHCS Commercial |
$3,867.49
|
| Rate for Payer: United Healthcare All Payer |
$3,545.20
|
|
|
SONICANCHOR 2.5X10 FIBER 2-0
|
Facility
|
IP
|
$4,028.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.72 |
| Max. Negotiated Rate |
$3,867.49 |
| Rate for Payer: Aetna Commercial |
$3,102.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.34
|
| Rate for Payer: Cash Price |
$2,014.32
|
| Rate for Payer: Cigna Commercial |
$3,343.77
|
| Rate for Payer: First Health Commercial |
$3,827.21
|
| Rate for Payer: Humana Commercial |
$3,424.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.88
|
| Rate for Payer: PHCS Commercial |
$3,867.49
|
| Rate for Payer: United Healthcare All Payer |
$3,545.20
|
|
|
SONICANCHOR 2.5X10 FIBER 2-0
|
Facility
|
OP
|
$4,028.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$523.72 |
| Max. Negotiated Rate |
$3,867.49 |
| Rate for Payer: Aetna Commercial |
$3,102.05
|
| Rate for Payer: Anthem Medicaid |
$1,385.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,142.34
|
| Rate for Payer: Cash Price |
$2,014.32
|
| Rate for Payer: Cigna Commercial |
$3,343.77
|
| Rate for Payer: First Health Commercial |
$3,827.21
|
| Rate for Payer: Humana Commercial |
$3,424.34
|
| Rate for Payer: Humana KY Medicaid |
$1,385.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,399.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,303.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,973.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,208.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,413.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,545.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,021.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$805.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$523.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,248.88
|
| Rate for Payer: PHCS Commercial |
$3,867.49
|
| Rate for Payer: United Healthcare All Payer |
$3,545.20
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR
|
Professional
|
Both
|
$1,020.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$45.31 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Aetna Commercial |
$182.48
|
| Rate for Payer: Anthem Medicaid |
$100.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,020.00
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cigna Commercial |
$156.50
|
| Rate for Payer: Healthspan PPO |
$170.98
|
| Rate for Payer: Humana Medicaid |
$100.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.99
|
| Rate for Payer: Molina Healthcare Passport |
$100.97
|
| Rate for Payer: Multiplan PHCS |
$612.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$714.00
|
| Rate for Payer: UHCCP Medicaid |
$357.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.98
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR
|
Facility
|
IP
|
$1,020.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$979.20 |
| Rate for Payer: Aetna Commercial |
$785.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$795.60
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cigna Commercial |
$846.60
|
| Rate for Payer: First Health Commercial |
$969.00
|
| Rate for Payer: Humana Commercial |
$867.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$836.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$752.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$306.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$897.60
|
| Rate for Payer: Ohio Health Group HMO |
$765.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$204.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$316.20
|
| Rate for Payer: PHCS Commercial |
$979.20
|
| Rate for Payer: United Healthcare All Payer |
$897.60
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR
|
Facility
|
OP
|
$1,020.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
40200045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$132.60 |
| Max. Negotiated Rate |
$979.20 |
| Rate for Payer: Aetna Commercial |
$785.40
|
| Rate for Payer: Anthem Medicaid |
$350.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$795.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cash Price |
$510.00
|
| Rate for Payer: Cigna Commercial |
$846.60
|
| Rate for Payer: First Health Commercial |
$969.00
|
| Rate for Payer: Humana Commercial |
$867.00
|
| Rate for Payer: Humana KY Medicaid |
$350.78
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$354.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$836.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$752.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$357.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$897.60
|
| Rate for Payer: Ohio Health Group HMO |
$765.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$204.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$132.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$316.20
|
| Rate for Payer: PHCS Commercial |
$979.20
|
| Rate for Payer: United Healthcare All Payer |
$897.60
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR(P
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
402P0045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$45.31 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$182.48
|
| Rate for Payer: Anthem Medicaid |
$100.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$156.50
|
| Rate for Payer: Healthspan PPO |
$170.98
|
| Rate for Payer: Humana Medicaid |
$100.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.99
|
| Rate for Payer: Molina Healthcare Passport |
$100.97
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.98
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR(T
|
Facility
|
IP
|
$785.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
402T0045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$102.05 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.35
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
SONOHYSTEROGRAPHY W/CLR DPLR(T
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 76831
|
| Hospital Charge Code |
402T0045
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$102.05 |
| Max. Negotiated Rate |
$753.60 |
| Rate for Payer: Aetna Commercial |
$604.45
|
| Rate for Payer: Anthem Medicaid |
$269.96
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$612.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cash Price |
$392.50
|
| Rate for Payer: Cigna Commercial |
$651.55
|
| Rate for Payer: First Health Commercial |
$745.75
|
| Rate for Payer: Humana Commercial |
$667.25
|
| Rate for Payer: Humana KY Medicaid |
$269.96
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$272.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$643.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$579.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$275.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$690.80
|
| Rate for Payer: Ohio Health Group HMO |
$588.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$157.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.35
|
| Rate for Payer: PHCS Commercial |
$753.60
|
| Rate for Payer: United Healthcare All Payer |
$690.80
|
|
|
SORBITOL 70% SOLUTION 30ML
|
Facility
|
OP
|
$10.78
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
25003477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: Anthem Medicaid |
$3.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.41
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna Commercial |
$8.95
|
| Rate for Payer: First Health Commercial |
$10.24
|
| Rate for Payer: Humana Commercial |
$9.16
|
| Rate for Payer: Humana KY Medicaid |
$3.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.49
|
| Rate for Payer: Ohio Health Group HMO |
$8.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$10.35
|
| Rate for Payer: United Healthcare All Payer |
$9.49
|
|
|
SORBITOL 70% SOLUTION 30ML
|
Facility
|
IP
|
$10.78
|
|
|
Service Code
|
NDC 46287050030
|
| Hospital Charge Code |
25003477
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.41
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna Commercial |
$8.95
|
| Rate for Payer: First Health Commercial |
$10.24
|
| Rate for Payer: Humana Commercial |
$9.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.49
|
| Rate for Payer: Ohio Health Group HMO |
$8.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$10.35
|
| Rate for Payer: United Healthcare All Payer |
$9.49
|
|
