|
BASIC COMP AUDIOLOGY
|
Facility
|
IP
|
$340.00
|
|
|
Service Code
|
HCPCS 92557
|
| Hospital Charge Code |
47000012
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.20
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$272.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$295.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.60
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
BASIC METABOLIC PANEL
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
30000005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$70.08 |
| Rate for Payer: Aetna Commercial |
$56.21
|
| Rate for Payer: Anthem Medicaid |
$8.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.46
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$60.59
|
| Rate for Payer: First Health Commercial |
$69.35
|
| Rate for Payer: Humana Commercial |
$62.05
|
| Rate for Payer: Humana KY Medicaid |
$8.46
|
| Rate for Payer: Humana Medicare Advantage |
$8.46
|
| Rate for Payer: Kentucky WC Medicaid |
$8.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.24
|
| Rate for Payer: Ohio Health Group HMO |
$54.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.37
|
| Rate for Payer: PHCS Commercial |
$70.08
|
| Rate for Payer: United Healthcare All Payer |
$64.24
|
|
|
BASIC METABOLIC PANEL
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
30000005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.08 |
| Max. Negotiated Rate |
$43.80 |
| Rate for Payer: Aetna Commercial |
$14.94
|
| Rate for Payer: Ambetter Exchange |
$8.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.46
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.15
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$7.44
|
| Rate for Payer: Healthspan PPO |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.46
|
| Rate for Payer: Multiplan PHCS |
$43.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.00
|
| Rate for Payer: UHCCP Medicaid |
$25.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.46
|
|
|
BASIC METABOLIC PANEL
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
30000005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$70.08 |
| Rate for Payer: Aetna Commercial |
$56.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.62
|
| Rate for Payer: Cash Price |
$36.50
|
| Rate for Payer: Cigna Commercial |
$60.59
|
| Rate for Payer: First Health Commercial |
$69.35
|
| Rate for Payer: Humana Commercial |
$62.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$64.24
|
| Rate for Payer: Ohio Health Group HMO |
$54.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.37
|
| Rate for Payer: PHCS Commercial |
$70.08
|
| Rate for Payer: United Healthcare All Payer |
$64.24
|
|
|
BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520)
|
Facility
|
OP
|
$11.84
|
|
|
Service Code
|
CPT 80048
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8.46 |
| Max. Negotiated Rate |
$11.84 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.42
|
| Rate for Payer: Humana Medicare Advantage |
$8.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.15
|
|
|
BASIC VESTIBULAR EVALUATION
|
Facility
|
OP
|
$561.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
47000004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$538.56 |
| Rate for Payer: Aetna Commercial |
$431.97
|
| Rate for Payer: Anthem Medicaid |
$192.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$437.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$465.63
|
| Rate for Payer: First Health Commercial |
$532.95
|
| Rate for Payer: Humana Commercial |
$476.85
|
| Rate for Payer: Humana KY Medicaid |
$192.93
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$194.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$460.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$414.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$493.68
|
| Rate for Payer: Ohio Health Group HMO |
$420.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$488.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.09
|
| Rate for Payer: PHCS Commercial |
$538.56
|
| Rate for Payer: United Healthcare All Payer |
$493.68
|
|
|
BASIC VESTIBULAR EVALUATION
|
Facility
|
IP
|
$561.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
47000004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$168.30 |
| Max. Negotiated Rate |
$538.56 |
| Rate for Payer: Aetna Commercial |
$431.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$437.58
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$465.63
|
| Rate for Payer: First Health Commercial |
$532.95
|
| Rate for Payer: Humana Commercial |
$476.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$460.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$414.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$168.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$493.68
|
| Rate for Payer: Ohio Health Group HMO |
$420.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$488.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.09
|
| Rate for Payer: PHCS Commercial |
$538.56
|
| Rate for Payer: United Healthcare All Payer |
$493.68
|
|
|
BASIC VESTIBULAR EVALUATION
|
Professional
|
Both
|
$561.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
47000004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$80.25 |
| Max. Negotiated Rate |
$336.60 |
| Rate for Payer: Aetna Commercial |
$147.26
|
| Rate for Payer: Ambetter Exchange |
$96.97
|
| Rate for Payer: Anthem Medicaid |
$80.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$96.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$96.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$116.36
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cash Price |
$280.50
|
| Rate for Payer: Cigna Commercial |
$154.86
|
| Rate for Payer: Healthspan PPO |
$94.80
|
| Rate for Payer: Humana Medicaid |
$80.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$96.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.86
|
| Rate for Payer: Molina Healthcare Passport |
$80.25
|
| Rate for Payer: Multiplan PHCS |
$336.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$126.06
|
| Rate for Payer: UHCCP Medicaid |
$196.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$96.97
|
|
|
BASIC VESTIBULAR EVALUATION(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
470P0004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$154.86 |
| Rate for Payer: Aetna Commercial |
$147.26
|
| Rate for Payer: Ambetter Exchange |
$96.97
|
| Rate for Payer: Anthem Medicaid |
$80.25
|
| Rate for Payer: Buckeye Individual/Medicaid |
$96.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$96.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$116.36
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$154.86
|
| Rate for Payer: Healthspan PPO |
$94.80
|
| Rate for Payer: Humana Medicaid |
$80.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$96.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.86
|
| Rate for Payer: Molina Healthcare Passport |
$80.25
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$126.06
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$81.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$96.97
|
|
|
BASIC VESTIBULAR EVALUATION(T
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
470T0004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$124.15 |
| Max. Negotiated Rate |
$346.56 |
| Rate for Payer: Aetna Commercial |
$277.97
|
| Rate for Payer: Anthem Medicaid |
$124.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$281.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cigna Commercial |
$299.63
|
| Rate for Payer: First Health Commercial |
$342.95
|
| Rate for Payer: Humana Commercial |
$306.85
|
| Rate for Payer: Humana KY Medicaid |
$124.15
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$125.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$296.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$266.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$126.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$317.68
|
| Rate for Payer: Ohio Health Group HMO |
$270.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$288.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$249.09
|
| Rate for Payer: PHCS Commercial |
$346.56
|
| Rate for Payer: United Healthcare All Payer |
$317.68
|
|
|
BASIC VESTIBULAR EVALUATION(T
|
Facility
|
IP
|
$361.00
|
|
|
Service Code
|
HCPCS 92540
|
| Hospital Charge Code |
470T0004
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$108.30 |
| Max. Negotiated Rate |
$346.56 |
| Rate for Payer: Aetna Commercial |
$277.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$281.58
|
| Rate for Payer: Cash Price |
$180.50
|
| Rate for Payer: Cigna Commercial |
$299.63
|
| Rate for Payer: First Health Commercial |
$342.95
|
| Rate for Payer: Humana Commercial |
$306.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$296.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$266.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$317.68
|
| Rate for Payer: Ohio Health Group HMO |
$270.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$288.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$249.09
|
| Rate for Payer: PHCS Commercial |
$346.56
|
| Rate for Payer: United Healthcare All Payer |
$317.68
|
|
|
BASKET SPYGLASS RETRIEVAL
|
Facility
|
OP
|
$2,212.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| 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
|
|
|
BASKET SPYGLASS RETRIEVAL
|
Facility
|
IP
|
$2,212.00
|
|
|
Service Code
|
HCPCS C1889
|
| Hospital Charge Code |
27000057
|
|
Hospital Revenue Code
|
275
|
| 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
|
|
|
BASSINET
|
Facility
|
IP
|
$3,512.00
|
|
| Hospital Charge Code |
17000001
|
|
Hospital Revenue Code
|
170
|
| Min. Negotiated Rate |
$1,170.00 |
| Max. Negotiated Rate |
$3,371.52 |
| Rate for Payer: Aetna Commercial |
$2,704.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.36
|
| Rate for Payer: Cash Price |
$1,756.00
|
| Rate for Payer: Cash Price |
$1,756.00
|
| Rate for Payer: Cigna Commercial |
$2,914.96
|
| Rate for Payer: First Health Commercial |
$3,336.40
|
| Rate for Payer: Humana Commercial |
$2,985.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,879.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,591.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,090.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,809.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,055.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,423.28
|
| Rate for Payer: PHCS Commercial |
$3,371.52
|
| Rate for Payer: United Healthcare All Payer |
$3,090.56
|
|
|
BASSINET INT
|
Facility
|
IP
|
$7,024.00
|
|
| Hospital Charge Code |
17000002
|
|
Hospital Revenue Code
|
170
|
| Min. Negotiated Rate |
$1,170.00 |
| Max. Negotiated Rate |
$6,743.04 |
| Rate for Payer: Aetna Commercial |
$5,408.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,478.72
|
| Rate for Payer: Cash Price |
$3,512.00
|
| Rate for Payer: Cash Price |
$3,512.00
|
| Rate for Payer: Cigna Commercial |
$5,829.92
|
| Rate for Payer: First Health Commercial |
$6,672.80
|
| Rate for Payer: Humana Commercial |
$5,970.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,759.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,183.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,170.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,181.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,268.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,619.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,110.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,846.56
|
| Rate for Payer: PHCS Commercial |
$6,743.04
|
| Rate for Payer: United Healthcare All Payer |
$6,181.12
|
|
|
BATTERY EACH-ZINC AIR
|
Facility
|
IP
|
$2.50
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
47000036
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$1.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.95
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna Commercial |
$2.08
|
| Rate for Payer: First Health Commercial |
$2.38
|
| Rate for Payer: Humana Commercial |
$2.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.20
|
| Rate for Payer: Ohio Health Group HMO |
$1.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.73
|
| Rate for Payer: PHCS Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Payer |
$2.20
|
|
|
BATTERY EACH-ZINC AIR
|
Facility
|
OP
|
$2.50
|
|
|
Service Code
|
HCPCS V5266
|
| Hospital Charge Code |
47000036
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.40 |
| Rate for Payer: Aetna Commercial |
$1.93
|
| Rate for Payer: Anthem Medicaid |
$0.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.95
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna Commercial |
$2.08
|
| Rate for Payer: First Health Commercial |
$2.38
|
| Rate for Payer: Humana Commercial |
$2.12
|
| Rate for Payer: Humana KY Medicaid |
$0.86
|
| Rate for Payer: Kentucky WC Medicaid |
$0.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.20
|
| Rate for Payer: Ohio Health Group HMO |
$1.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.73
|
| Rate for Payer: PHCS Commercial |
$2.40
|
| Rate for Payer: United Healthcare All Payer |
$2.20
|
|
|
BATTERY EACH ZINC AIR SP
|
Professional
|
Both
|
$2.50
|
|
| Hospital Charge Code |
47000103
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$0.88 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Multiplan PHCS |
$1.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.75
|
| Rate for Payer: UHCCP Medicaid |
$0.88
|
|
|
BAXDELA 300MG VIAL
|
Facility
|
IP
|
$576.95
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002874
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$173.09 |
| Max. Negotiated Rate |
$553.87 |
| Rate for Payer: Aetna Commercial |
$444.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.02
|
| Rate for Payer: Cash Price |
$288.48
|
| Rate for Payer: Cigna Commercial |
$478.87
|
| Rate for Payer: First Health Commercial |
$548.10
|
| Rate for Payer: Humana Commercial |
$490.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$425.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$507.72
|
| Rate for Payer: Ohio Health Group HMO |
$432.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$461.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.10
|
| Rate for Payer: PHCS Commercial |
$553.87
|
| Rate for Payer: United Healthcare All Payer |
$507.72
|
|
|
BAXDELA 300MG VIAL
|
Facility
|
OP
|
$576.95
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002874
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$173.09 |
| Max. Negotiated Rate |
$553.87 |
| Rate for Payer: Aetna Commercial |
$444.25
|
| Rate for Payer: Anthem Medicaid |
$198.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.02
|
| Rate for Payer: Cash Price |
$288.48
|
| Rate for Payer: Cigna Commercial |
$478.87
|
| Rate for Payer: First Health Commercial |
$548.10
|
| Rate for Payer: Humana Commercial |
$490.41
|
| Rate for Payer: Humana KY Medicaid |
$198.41
|
| Rate for Payer: Kentucky WC Medicaid |
$200.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$425.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$202.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$507.72
|
| Rate for Payer: Ohio Health Group HMO |
$432.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$461.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$501.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.10
|
| Rate for Payer: PHCS Commercial |
$553.87
|
| Rate for Payer: United Healthcare All Payer |
$507.72
|
|
|
BAXDELA 450MG TABLET
|
Facility
|
IP
|
$155.66
|
|
|
Service Code
|
NDC 70842010101
|
| Hospital Charge Code |
25002875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.70 |
| Max. Negotiated Rate |
$149.43 |
| Rate for Payer: Aetna Commercial |
$119.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.41
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$147.88
|
| Rate for Payer: Humana Commercial |
$132.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.98
|
| Rate for Payer: Ohio Health Group HMO |
$116.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.41
|
| Rate for Payer: PHCS Commercial |
$149.43
|
| Rate for Payer: United Healthcare All Payer |
$136.98
|
|
|
BAXDELA 450MG TABLET
|
Facility
|
OP
|
$155.66
|
|
|
Service Code
|
NDC 70842010101
|
| Hospital Charge Code |
25002875
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.70 |
| Max. Negotiated Rate |
$149.43 |
| Rate for Payer: Aetna Commercial |
$119.86
|
| Rate for Payer: Anthem Medicaid |
$53.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121.41
|
| Rate for Payer: Cash Price |
$77.83
|
| Rate for Payer: Cigna Commercial |
$129.20
|
| Rate for Payer: First Health Commercial |
$147.88
|
| Rate for Payer: Humana Commercial |
$132.31
|
| Rate for Payer: Humana KY Medicaid |
$53.53
|
| Rate for Payer: Kentucky WC Medicaid |
$54.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$54.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$136.98
|
| Rate for Payer: Ohio Health Group HMO |
$116.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.41
|
| Rate for Payer: PHCS Commercial |
$149.43
|
| Rate for Payer: United Healthcare All Payer |
$136.98
|
|
|
BAYHEP B (HEP B IMMGLOBU)
|
Facility
|
IP
|
$357.45
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
25000001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$107.23 |
| Max. Negotiated Rate |
$343.15 |
| Rate for Payer: Aetna Commercial |
$275.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$278.81
|
| Rate for Payer: Cash Price |
$178.72
|
| Rate for Payer: Cigna Commercial |
$296.68
|
| Rate for Payer: First Health Commercial |
$339.58
|
| Rate for Payer: Humana Commercial |
$303.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$293.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$263.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$107.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$314.56
|
| Rate for Payer: Ohio Health Group HMO |
$268.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$285.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$310.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.64
|
| Rate for Payer: PHCS Commercial |
$343.15
|
| Rate for Payer: United Healthcare All Payer |
$314.56
|
|
|
BAYHEP B (HEP B IMMGLOBU)
|
Facility
|
OP
|
$357.45
|
|
|
Service Code
|
HCPCS 90371
|
| Hospital Charge Code |
25000001
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$122.93 |
| Max. Negotiated Rate |
$343.15 |
| Rate for Payer: Aetna Commercial |
$275.24
|
| Rate for Payer: Anthem Medicaid |
$122.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$130.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$278.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$182.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$176.39
|
| Rate for Payer: Cash Price |
$178.72
|
| Rate for Payer: Cash Price |
$178.72
|
| Rate for Payer: Cigna Commercial |
$296.68
|
| Rate for Payer: First Health Commercial |
$339.58
|
| Rate for Payer: Humana Commercial |
$303.83
|
| Rate for Payer: Humana KY Medicaid |
$122.93
|
| Rate for Payer: Humana Medicare Advantage |
$130.66
|
| Rate for Payer: Kentucky WC Medicaid |
$124.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$293.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$263.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$125.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$314.56
|
| Rate for Payer: Ohio Health Group HMO |
$268.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$285.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$310.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.64
|
| Rate for Payer: PHCS Commercial |
$343.15
|
| Rate for Payer: United Healthcare All Payer |
$314.56
|
|
|
BBL AA Full Face
|
Professional
|
Both
|
$350.00
|
|
| Hospital Charge Code |
22200265
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
|
