|
STEREOTACTIC SBRT 1-5 FRACTION
|
Facility
|
IP
|
$19,885.00
|
|
|
Service Code
|
HCPCS 77373
|
| Hospital Charge Code |
33300020
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,585.05 |
| Max. Negotiated Rate |
$19,089.60 |
| Rate for Payer: Aetna Commercial |
$15,311.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,510.30
|
| Rate for Payer: Cash Price |
$9,942.50
|
| Rate for Payer: Cigna Commercial |
$16,504.55
|
| Rate for Payer: First Health Commercial |
$18,890.75
|
| Rate for Payer: Humana Commercial |
$16,902.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,305.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,675.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,965.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,498.80
|
| Rate for Payer: Ohio Health Group HMO |
$14,913.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,977.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,585.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,164.35
|
| Rate for Payer: PHCS Commercial |
$19,089.60
|
| Rate for Payer: United Healthcare All Payer |
$17,498.80
|
|
|
STERILE SCREW RIB MAXDRIVE
|
Facility
|
IP
|
$11,923.12
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,550.01 |
| Max. Negotiated Rate |
$11,446.20 |
| Rate for Payer: Aetna Commercial |
$9,180.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,300.03
|
| Rate for Payer: Cash Price |
$5,961.56
|
| Rate for Payer: Cigna Commercial |
$9,896.19
|
| Rate for Payer: First Health Commercial |
$11,326.96
|
| Rate for Payer: Humana Commercial |
$10,134.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,776.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,799.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,576.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,492.35
|
| Rate for Payer: Ohio Health Group HMO |
$8,942.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,384.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,550.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,696.17
|
| Rate for Payer: PHCS Commercial |
$11,446.20
|
| Rate for Payer: United Healthcare All Payer |
$10,492.35
|
|
|
STERILE SCREW RIB MAXDRIVE
|
Facility
|
OP
|
$11,923.12
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,550.01 |
| Max. Negotiated Rate |
$11,446.20 |
| Rate for Payer: Aetna Commercial |
$9,180.80
|
| Rate for Payer: Anthem Medicaid |
$4,100.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,300.03
|
| Rate for Payer: Cash Price |
$5,961.56
|
| Rate for Payer: Cigna Commercial |
$9,896.19
|
| Rate for Payer: First Health Commercial |
$11,326.96
|
| Rate for Payer: Humana Commercial |
$10,134.65
|
| Rate for Payer: Humana KY Medicaid |
$4,100.36
|
| Rate for Payer: Kentucky WC Medicaid |
$4,142.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,776.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,799.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,576.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,182.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,492.35
|
| Rate for Payer: Ohio Health Group HMO |
$8,942.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,384.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,550.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,696.17
|
| Rate for Payer: PHCS Commercial |
$11,446.20
|
| Rate for Payer: United Healthcare All Payer |
$10,492.35
|
|
|
STERILE WATER 5ML FOR INJ VL
|
Facility
|
OP
|
$10.95
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
25003490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Aetna Commercial |
$8.43
|
| Rate for Payer: Anthem Medicaid |
$3.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.54
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Cigna Commercial |
$9.09
|
| Rate for Payer: First Health Commercial |
$10.40
|
| Rate for Payer: Humana Commercial |
$9.31
|
| Rate for Payer: Humana KY Medicaid |
$3.77
|
| Rate for Payer: Kentucky WC Medicaid |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.64
|
| Rate for Payer: Ohio Health Group HMO |
$8.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.39
|
| Rate for Payer: PHCS Commercial |
$10.51
|
| Rate for Payer: United Healthcare All Payer |
$9.64
|
|
|
STERILE WATER 5ML FOR INJ VL
|
Facility
|
IP
|
$10.95
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
25003490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$10.51 |
| Rate for Payer: Aetna Commercial |
$8.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.54
|
| Rate for Payer: Cash Price |
$5.47
|
| Rate for Payer: Cigna Commercial |
$9.09
|
| Rate for Payer: First Health Commercial |
$10.40
|
| Rate for Payer: Humana Commercial |
$9.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.64
|
| Rate for Payer: Ohio Health Group HMO |
$8.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.39
|
| Rate for Payer: PHCS Commercial |
$10.51
|
| Rate for Payer: United Healthcare All Payer |
$9.64
|
|
|
STERILE WATER FOR INJ
|
Facility
|
IP
|
$22.24
|
|
|
Service Code
|
NDC 990711807
|
| Hospital Charge Code |
25003491
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.35 |
| Rate for Payer: Aetna Commercial |
$17.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.35
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.46
|
| Rate for Payer: First Health Commercial |
$21.13
|
| Rate for Payer: Humana Commercial |
$18.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.57
|
| Rate for Payer: Ohio Health Group HMO |
$16.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$21.35
|
| Rate for Payer: United Healthcare All Payer |
$19.57
|
|
|
STERILE WATER FOR INJ
|
Facility
|
OP
|
$22.24
|
|
|
Service Code
|
NDC 990711807
|
| Hospital Charge Code |
25003491
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.35 |
| Rate for Payer: Aetna Commercial |
$17.12
|
| Rate for Payer: Anthem Medicaid |
$7.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.35
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.46
|
| Rate for Payer: First Health Commercial |
$21.13
|
| Rate for Payer: Humana Commercial |
$18.90
|
| Rate for Payer: Humana KY Medicaid |
$7.65
|
| Rate for Payer: Kentucky WC Medicaid |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.57
|
| Rate for Payer: Ohio Health Group HMO |
$16.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.89
|
| Rate for Payer: PHCS Commercial |
$21.35
|
| Rate for Payer: United Healthcare All Payer |
$19.57
|
|
|
STERILE WATER FOR INJEC 1000ML
|
Facility
|
IP
|
$112.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25003492
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.59 |
| Max. Negotiated Rate |
$107.76 |
| Rate for Payer: Aetna Commercial |
$86.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.56
|
| Rate for Payer: Cash Price |
$56.12
|
| Rate for Payer: Cigna Commercial |
$93.17
|
| Rate for Payer: First Health Commercial |
$106.64
|
| Rate for Payer: Humana Commercial |
$95.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.78
|
| Rate for Payer: Ohio Health Group HMO |
$84.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.80
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
STERILE WATER FOR INJEC 1000ML
|
Facility
|
OP
|
$112.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25003492
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$14.59 |
| Max. Negotiated Rate |
$107.76 |
| Rate for Payer: Aetna Commercial |
$86.43
|
| Rate for Payer: Anthem Medicaid |
$38.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.56
|
| Rate for Payer: Cash Price |
$56.12
|
| Rate for Payer: Cigna Commercial |
$93.17
|
| Rate for Payer: First Health Commercial |
$106.64
|
| Rate for Payer: Humana Commercial |
$95.41
|
| Rate for Payer: Humana KY Medicaid |
$38.60
|
| Rate for Payer: Kentucky WC Medicaid |
$39.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.78
|
| Rate for Payer: Ohio Health Group HMO |
$84.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.80
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
STERILE WATER IRR 500mL BOTTLE
|
Facility
|
OP
|
$11.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004358
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Aetna Commercial |
$8.66
|
| Rate for Payer: Anthem Medicaid |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.78
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cigna Commercial |
$9.34
|
| Rate for Payer: First Health Commercial |
$10.69
|
| Rate for Payer: Humana Commercial |
$9.56
|
| Rate for Payer: Humana KY Medicaid |
$3.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.90
|
| Rate for Payer: Ohio Health Group HMO |
$8.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$10.80
|
| Rate for Payer: United Healthcare All Payer |
$9.90
|
|
|
STERILE WATER IRR 500mL BOTTLE
|
Facility
|
IP
|
$11.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004358
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Aetna Commercial |
$8.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.78
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cigna Commercial |
$9.34
|
| Rate for Payer: First Health Commercial |
$10.69
|
| Rate for Payer: Humana Commercial |
$9.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.90
|
| Rate for Payer: Ohio Health Group HMO |
$8.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$10.80
|
| Rate for Payer: United Healthcare All Payer |
$9.90
|
|
|
STERILE WATER IRRIG 250ML
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 990613922
|
| Hospital Charge Code |
25004355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
STERILE WATER IRRIG 250ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990613922
|
| Hospital Charge Code |
25004355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem Medicaid |
$7.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Humana KY Medicaid |
$7.65
|
| Rate for Payer: Kentucky WC Medicaid |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
STERILE WATER IRRIGAT 1500ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990713936
|
| Hospital Charge Code |
25003489
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem Medicaid |
$7.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Humana KY Medicaid |
$7.65
|
| Rate for Payer: Kentucky WC Medicaid |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
STERILE WATER IRRIGAT 1500ML
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 990713936
|
| Hospital Charge Code |
25003489
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.89 |
| Max. Negotiated Rate |
$21.36 |
| Rate for Payer: Aetna Commercial |
$17.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.36
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: Cigna Commercial |
$18.47
|
| Rate for Payer: First Health Commercial |
$21.14
|
| Rate for Payer: Humana Commercial |
$18.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.58
|
| Rate for Payer: Ohio Health Group HMO |
$16.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
STERILE WATER IRRIGAT 2000ML
|
Facility
|
IP
|
$121.90
|
|
|
Service Code
|
NDC 264738650
|
| Hospital Charge Code |
25003493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$117.02 |
| Rate for Payer: Aetna Commercial |
$93.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.08
|
| Rate for Payer: Cash Price |
$60.95
|
| Rate for Payer: Cigna Commercial |
$101.18
|
| Rate for Payer: First Health Commercial |
$115.80
|
| Rate for Payer: Humana Commercial |
$103.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.27
|
| Rate for Payer: Ohio Health Group HMO |
$91.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.79
|
| Rate for Payer: PHCS Commercial |
$117.02
|
| Rate for Payer: United Healthcare All Payer |
$107.27
|
|
|
STERILE WATER IRRIGAT 2000ML
|
Facility
|
OP
|
$121.90
|
|
|
Service Code
|
NDC 264738650
|
| Hospital Charge Code |
25003493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.85 |
| Max. Negotiated Rate |
$117.02 |
| Rate for Payer: Aetna Commercial |
$93.86
|
| Rate for Payer: Anthem Medicaid |
$41.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.08
|
| Rate for Payer: Cash Price |
$60.95
|
| Rate for Payer: Cigna Commercial |
$101.18
|
| Rate for Payer: First Health Commercial |
$115.80
|
| Rate for Payer: Humana Commercial |
$103.62
|
| Rate for Payer: Humana KY Medicaid |
$41.92
|
| Rate for Payer: Kentucky WC Medicaid |
$42.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.27
|
| Rate for Payer: Ohio Health Group HMO |
$91.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.79
|
| Rate for Payer: PHCS Commercial |
$117.02
|
| Rate for Payer: United Healthcare All Payer |
$107.27
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
IP
|
$80.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25004257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Aetna Commercial |
$61.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.60
|
| Rate for Payer: Cash Price |
$40.12
|
| Rate for Payer: Cigna Commercial |
$66.61
|
| Rate for Payer: First Health Commercial |
$76.24
|
| Rate for Payer: Humana Commercial |
$68.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.62
|
| Rate for Payer: Ohio Health Group HMO |
$60.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.88
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Professional
|
Both
|
$51.99
|
|
| Hospital Charge Code |
63600171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$51.99 |
| Rate for Payer: Buckeye Medicare Advantage |
$51.99
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Multiplan PHCS |
$31.19
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$36.39
|
| Rate for Payer: UHCCP Medicaid |
$18.20
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
OP
|
$51.99
|
|
| Hospital Charge Code |
63600171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$49.91 |
| Rate for Payer: Aetna Commercial |
$40.03
|
| Rate for Payer: Anthem Medicaid |
$17.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.55
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.15
|
| Rate for Payer: First Health Commercial |
$49.39
|
| Rate for Payer: Humana Commercial |
$44.19
|
| Rate for Payer: Humana KY Medicaid |
$17.88
|
| Rate for Payer: Kentucky WC Medicaid |
$18.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.75
|
| Rate for Payer: Ohio Health Group HMO |
$38.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.12
|
| Rate for Payer: PHCS Commercial |
$49.91
|
| Rate for Payer: United Healthcare All Payer |
$45.75
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
IP
|
$51.99
|
|
| Hospital Charge Code |
636T0171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$49.91 |
| Rate for Payer: Aetna Commercial |
$40.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.55
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.15
|
| Rate for Payer: First Health Commercial |
$49.39
|
| Rate for Payer: Humana Commercial |
$44.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.75
|
| Rate for Payer: Ohio Health Group HMO |
$38.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.12
|
| Rate for Payer: PHCS Commercial |
$49.91
|
| Rate for Payer: United Healthcare All Payer |
$45.75
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
IP
|
$51.99
|
|
| Hospital Charge Code |
63600171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$49.91 |
| Rate for Payer: Aetna Commercial |
$40.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.55
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.15
|
| Rate for Payer: First Health Commercial |
$49.39
|
| Rate for Payer: Humana Commercial |
$44.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.75
|
| Rate for Payer: Ohio Health Group HMO |
$38.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.12
|
| Rate for Payer: PHCS Commercial |
$49.91
|
| Rate for Payer: United Healthcare All Payer |
$45.75
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
OP
|
$51.99
|
|
| Hospital Charge Code |
636T0171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$49.91 |
| Rate for Payer: Aetna Commercial |
$40.03
|
| Rate for Payer: Anthem Medicaid |
$17.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$40.55
|
| Rate for Payer: Cash Price |
$26.00
|
| Rate for Payer: Cigna Commercial |
$43.15
|
| Rate for Payer: First Health Commercial |
$49.39
|
| Rate for Payer: Humana Commercial |
$44.19
|
| Rate for Payer: Humana KY Medicaid |
$17.88
|
| Rate for Payer: Kentucky WC Medicaid |
$18.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$42.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$38.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$45.75
|
| Rate for Payer: Ohio Health Group HMO |
$38.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.12
|
| Rate for Payer: PHCS Commercial |
$49.91
|
| Rate for Payer: United Healthcare All Payer |
$45.75
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
OP
|
$80.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25004257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.43 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Aetna Commercial |
$61.79
|
| Rate for Payer: Anthem Medicaid |
$27.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.60
|
| Rate for Payer: Cash Price |
$40.12
|
| Rate for Payer: Cigna Commercial |
$66.61
|
| Rate for Payer: First Health Commercial |
$76.24
|
| Rate for Payer: Humana Commercial |
$68.21
|
| Rate for Payer: Humana KY Medicaid |
$27.60
|
| Rate for Payer: Kentucky WC Medicaid |
$27.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.62
|
| Rate for Payer: Ohio Health Group HMO |
$60.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.88
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 3L
|
Facility
|
IP
|
$85.71
|
|
| Hospital Charge Code |
636T0172
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.14 |
| Max. Negotiated Rate |
$82.28 |
| Rate for Payer: Aetna Commercial |
$66.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.85
|
| Rate for Payer: Cash Price |
$42.85
|
| Rate for Payer: Cigna Commercial |
$71.14
|
| Rate for Payer: First Health Commercial |
$81.42
|
| Rate for Payer: Humana Commercial |
$72.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.42
|
| Rate for Payer: Ohio Health Group HMO |
$64.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.57
|
| Rate for Payer: PHCS Commercial |
$82.28
|
| Rate for Payer: United Healthcare All Payer |
$75.42
|
|
