|
BACTERLOSTATIC WTR INJ VL 30ML
|
Facility
|
IP
|
$113.27
|
|
|
Service Code
|
NDC 409397703
|
| Hospital Charge Code |
25002871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.98 |
| Max. Negotiated Rate |
$108.74 |
| Rate for Payer: Aetna Commercial |
$87.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.35
|
| Rate for Payer: Cash Price |
$56.63
|
| Rate for Payer: Cigna Commercial |
$94.01
|
| Rate for Payer: First Health Commercial |
$107.61
|
| Rate for Payer: Humana Commercial |
$96.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.68
|
| Rate for Payer: Ohio Health Group HMO |
$84.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.16
|
| Rate for Payer: PHCS Commercial |
$108.74
|
| Rate for Payer: United Healthcare All Payer |
$99.68
|
|
|
BACTERLOSTATIC WTR INJ VL 30ML
|
Facility
|
OP
|
$113.27
|
|
|
Service Code
|
NDC 409397703
|
| Hospital Charge Code |
25002871
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.98 |
| Max. Negotiated Rate |
$108.74 |
| Rate for Payer: Aetna Commercial |
$87.22
|
| Rate for Payer: Anthem Medicaid |
$38.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.35
|
| Rate for Payer: Cash Price |
$56.63
|
| Rate for Payer: Cigna Commercial |
$94.01
|
| Rate for Payer: First Health Commercial |
$107.61
|
| Rate for Payer: Humana Commercial |
$96.28
|
| Rate for Payer: Humana KY Medicaid |
$38.95
|
| Rate for Payer: Kentucky WC Medicaid |
$39.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.68
|
| Rate for Payer: Ohio Health Group HMO |
$84.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.16
|
| Rate for Payer: PHCS Commercial |
$108.74
|
| Rate for Payer: United Healthcare All Payer |
$99.68
|
|
|
BACTRIM DS (SULFAM-TR TAB/1TAB
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 60687061401
|
| Hospital Charge Code |
25000307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
BACTRIM DS (SULFAM-TR TAB/1TAB
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 60687061401
|
| Hospital Charge Code |
25000307
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
BACTRIM (SULFAME-TRIMETHO 1TAB
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 57237023201
|
| Hospital Charge Code |
25000306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
BACTRIM (SULFAME-TRIMETHO 1TAB
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 57237023201
|
| Hospital Charge Code |
25000306
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.94
|
| Rate for Payer: PHCS Commercial |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
BACTROBAN (MUPIROCIN) 22 GRAM
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002872
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna Commercial |
$2.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.98
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna Commercial |
$3.17
|
| Rate for Payer: First Health Commercial |
$3.63
|
| Rate for Payer: Humana Commercial |
$3.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.36
|
| Rate for Payer: Ohio Health Group HMO |
$2.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.64
|
| Rate for Payer: PHCS Commercial |
$3.67
|
| Rate for Payer: United Healthcare All Payer |
$3.36
|
|
|
BACTROBAN (MUPIROCIN) 22 GRAM
|
Facility
|
OP
|
$3.82
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002872
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$3.67 |
| Rate for Payer: Aetna Commercial |
$2.94
|
| Rate for Payer: Anthem Medicaid |
$1.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.98
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna Commercial |
$3.17
|
| Rate for Payer: First Health Commercial |
$3.63
|
| Rate for Payer: Humana Commercial |
$3.25
|
| Rate for Payer: Humana KY Medicaid |
$1.31
|
| Rate for Payer: Kentucky WC Medicaid |
$1.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.36
|
| Rate for Payer: Ohio Health Group HMO |
$2.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.64
|
| Rate for Payer: PHCS Commercial |
$3.67
|
| Rate for Payer: United Healthcare All Payer |
$3.36
|
|
|
BAKRI TAMPONADE BALLOON
|
Facility
|
OP
|
$3,101.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$930.52 |
| Max. Negotiated Rate |
$2,977.68 |
| Rate for Payer: Aetna Commercial |
$2,388.35
|
| Rate for Payer: Anthem Medicaid |
$1,066.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,419.36
|
| Rate for Payer: Cash Price |
$1,550.88
|
| Rate for Payer: Cigna Commercial |
$2,574.45
|
| Rate for Payer: First Health Commercial |
$2,946.66
|
| Rate for Payer: Humana Commercial |
$2,636.49
|
| Rate for Payer: Humana KY Medicaid |
$1,066.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,077.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,543.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,289.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,088.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,729.54
|
| Rate for Payer: Ohio Health Group HMO |
$2,326.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,698.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.21
|
| Rate for Payer: PHCS Commercial |
$2,977.68
|
| Rate for Payer: United Healthcare All Payer |
$2,729.54
|
|
|
BAKRI TAMPONADE BALLOON
|
Facility
|
IP
|
$3,101.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$930.52 |
| Max. Negotiated Rate |
$2,977.68 |
| Rate for Payer: Aetna Commercial |
$2,388.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,419.36
|
| Rate for Payer: Cash Price |
$1,550.88
|
| Rate for Payer: Cigna Commercial |
$2,574.45
|
| Rate for Payer: First Health Commercial |
$2,946.66
|
| Rate for Payer: Humana Commercial |
$2,636.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,543.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,289.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,729.54
|
| Rate for Payer: Ohio Health Group HMO |
$2,326.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,698.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.21
|
| Rate for Payer: PHCS Commercial |
$2,977.68
|
| Rate for Payer: United Healthcare All Payer |
$2,729.54
|
|
|
BAL FLUID CELL COUNT
|
Facility
|
IP
|
$97.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
30001545
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.10 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna Commercial |
$74.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.89
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cigna Commercial |
$80.51
|
| Rate for Payer: First Health Commercial |
$92.15
|
| Rate for Payer: Humana Commercial |
$82.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$79.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$71.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.36
|
| Rate for Payer: Ohio Health Group HMO |
$72.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$77.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.93
|
| Rate for Payer: PHCS Commercial |
$93.12
|
| Rate for Payer: United Healthcare All Payer |
$85.36
|
|
|
BAL FLUID CELL COUNT
|
Facility
|
OP
|
$97.00
|
|
|
Service Code
|
HCPCS 89051
|
| Hospital Charge Code |
30001545
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.60 |
| Max. Negotiated Rate |
$93.12 |
| Rate for Payer: Aetna Commercial |
$74.69
|
| Rate for Payer: Anthem Medicaid |
$5.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cash Price |
$48.50
|
| Rate for Payer: Cigna Commercial |
$80.51
|
| Rate for Payer: First Health Commercial |
$92.15
|
| Rate for Payer: Humana Commercial |
$82.45
|
| Rate for Payer: Humana KY Medicaid |
$5.60
|
| Rate for Payer: Humana Medicare Advantage |
$5.60
|
| Rate for Payer: Kentucky WC Medicaid |
$5.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$79.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$71.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.36
|
| Rate for Payer: Ohio Health Group HMO |
$72.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$77.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.93
|
| Rate for Payer: PHCS Commercial |
$93.12
|
| Rate for Payer: United Healthcare All Payer |
$85.36
|
|
|
BALLOON 6 X 4
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BALLOON 6 X 4
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BALLOON 9 X 4
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BALLOON 9 X 4
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BALLOON CATH 6215-80
|
Facility
|
OP
|
$1,549.60
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$464.88 |
| Max. Negotiated Rate |
$1,487.62 |
| Rate for Payer: Aetna Commercial |
$1,193.19
|
| Rate for Payer: Anthem Medicaid |
$532.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,208.69
|
| Rate for Payer: Cash Price |
$774.80
|
| Rate for Payer: Cigna Commercial |
$1,286.17
|
| Rate for Payer: First Health Commercial |
$1,472.12
|
| Rate for Payer: Humana Commercial |
$1,317.16
|
| Rate for Payer: Humana KY Medicaid |
$532.91
|
| Rate for Payer: Kentucky WC Medicaid |
$538.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,270.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,143.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,363.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,162.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,239.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,348.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,069.22
|
| Rate for Payer: PHCS Commercial |
$1,487.62
|
| Rate for Payer: United Healthcare All Payer |
$1,363.65
|
|
|
BALLOON CATH 6215-80
|
Facility
|
IP
|
$1,549.60
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$464.88 |
| Max. Negotiated Rate |
$1,487.62 |
| Rate for Payer: Aetna Commercial |
$1,193.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,208.69
|
| Rate for Payer: Cash Price |
$774.80
|
| Rate for Payer: Cigna Commercial |
$1,286.17
|
| Rate for Payer: First Health Commercial |
$1,472.12
|
| Rate for Payer: Humana Commercial |
$1,317.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,270.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,143.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,363.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,162.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,239.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,348.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,069.22
|
| Rate for Payer: PHCS Commercial |
$1,487.62
|
| Rate for Payer: United Healthcare All Payer |
$1,363.65
|
|
|
BALLOON CATH 6225 ATTAIN CLARI
|
Facility
|
OP
|
$1,775.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem Medicaid |
$610.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Humana KY Medicaid |
$610.42
|
| Rate for Payer: Kentucky WC Medicaid |
$616.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$622.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
|
BALLOON CATH 6225 ATTAIN CLARI
|
Facility
|
IP
|
$1,775.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
|
BALLOON CATHETER 02-0764-00
|
Facility
|
OP
|
$2,212.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$663.60 |
| Max. Negotiated Rate |
$2,123.52 |
| Rate for Payer: Aetna Commercial |
$1,703.24
|
| Rate for Payer: Anthem Medicaid |
$760.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.36
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cigna Commercial |
$1,835.96
|
| Rate for Payer: First Health Commercial |
$2,101.40
|
| Rate for Payer: Humana Commercial |
$1,880.20
|
| Rate for Payer: Humana KY Medicaid |
$760.71
|
| Rate for Payer: Kentucky WC Medicaid |
$768.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$775.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,659.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.28
|
| Rate for Payer: PHCS Commercial |
$2,123.52
|
| Rate for Payer: United Healthcare All Payer |
$1,946.56
|
|
|
BALLOON CATHETER 02-0764-00
|
Facility
|
IP
|
$2,212.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$663.60 |
| Max. Negotiated Rate |
$2,123.52 |
| Rate for Payer: Aetna Commercial |
$1,703.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.36
|
| Rate for Payer: Cash Price |
$1,106.00
|
| Rate for Payer: Cigna Commercial |
$1,835.96
|
| Rate for Payer: First Health Commercial |
$2,101.40
|
| Rate for Payer: Humana Commercial |
$1,880.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,659.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.28
|
| Rate for Payer: PHCS Commercial |
$2,123.52
|
| Rate for Payer: United Healthcare All Payer |
$1,946.56
|
|
|
BALLOON CATHETER B5-2C
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BALLOON CATHETER B5-2C
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
BALLOON CATHETER BVCS6180
|
Facility
|
IP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
