|
STERILE SCREW RIB MAXDRIVE
|
Facility
|
IP
|
$12,170.38
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,651.11 |
| Max. Negotiated Rate |
$11,683.56 |
| Rate for Payer: Aetna Commercial |
$9,371.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,492.90
|
| Rate for Payer: Cash Price |
$6,085.19
|
| Rate for Payer: Cigna Commercial |
$10,101.42
|
| Rate for Payer: First Health Commercial |
$11,561.86
|
| Rate for Payer: Humana Commercial |
$10,344.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,979.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,981.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,651.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,709.93
|
| Rate for Payer: Ohio Health Group HMO |
$9,127.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,736.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,588.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,397.56
|
| Rate for Payer: PHCS Commercial |
$11,683.56
|
| Rate for Payer: United Healthcare All Payer |
$10,709.93
|
|
|
STERILE WATER 5ML FOR INJ VL
|
Facility
|
IP
|
$11.36
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
25003490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.91 |
| Rate for Payer: Aetna Commercial |
$8.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.86
|
| Rate for Payer: Cash Price |
$5.68
|
| Rate for Payer: Cigna Commercial |
$9.43
|
| Rate for Payer: First Health Commercial |
$10.79
|
| Rate for Payer: Humana Commercial |
$9.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.00
|
| Rate for Payer: Ohio Health Group HMO |
$8.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.84
|
| Rate for Payer: PHCS Commercial |
$10.91
|
| Rate for Payer: United Healthcare All Payer |
$10.00
|
|
|
STERILE WATER 5ML FOR INJ VL
|
Facility
|
OP
|
$11.36
|
|
|
Service Code
|
NDC 63323018505
|
| Hospital Charge Code |
25003490
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$10.91 |
| Rate for Payer: Aetna Commercial |
$8.75
|
| Rate for Payer: Anthem Medicaid |
$3.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.86
|
| Rate for Payer: Cash Price |
$5.68
|
| Rate for Payer: Cigna Commercial |
$9.43
|
| Rate for Payer: First Health Commercial |
$10.79
|
| Rate for Payer: Humana Commercial |
$9.66
|
| Rate for Payer: Humana KY Medicaid |
$3.91
|
| Rate for Payer: Kentucky WC Medicaid |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.00
|
| Rate for Payer: Ohio Health Group HMO |
$8.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.84
|
| Rate for Payer: PHCS Commercial |
$10.91
|
| Rate for Payer: United Healthcare All Payer |
$10.00
|
|
|
STERILE WATER FOR INJ
|
Facility
|
OP
|
$27.08
|
|
|
Service Code
|
NDC 990711807
|
| Hospital Charge Code |
25003491
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$20.85
|
| Rate for Payer: Anthem Medicaid |
$9.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.12
|
| Rate for Payer: Cash Price |
$13.54
|
| Rate for Payer: Cigna Commercial |
$22.48
|
| Rate for Payer: First Health Commercial |
$25.73
|
| Rate for Payer: Humana Commercial |
$23.02
|
| Rate for Payer: Humana KY Medicaid |
$9.31
|
| Rate for Payer: Kentucky WC Medicaid |
$9.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.83
|
| Rate for Payer: Ohio Health Group HMO |
$20.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.69
|
| Rate for Payer: PHCS Commercial |
$26.00
|
| Rate for Payer: United Healthcare All Payer |
$23.83
|
|
|
STERILE WATER FOR INJ
|
Facility
|
IP
|
$27.08
|
|
|
Service Code
|
NDC 990711807
|
| Hospital Charge Code |
25003491
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$8.12 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna Commercial |
$20.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.12
|
| Rate for Payer: Cash Price |
$13.54
|
| Rate for Payer: Cigna Commercial |
$22.48
|
| Rate for Payer: First Health Commercial |
$25.73
|
| Rate for Payer: Humana Commercial |
$23.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.83
|
| Rate for Payer: Ohio Health Group HMO |
$20.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.69
|
| Rate for Payer: PHCS Commercial |
$26.00
|
| Rate for Payer: United Healthcare All Payer |
$23.83
|
|
|
STERILE WATER FOR INJEC 1000ML
|
Facility
|
IP
|
$112.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25003492
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$33.67 |
| 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 |
$92.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| 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 |
$89.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.45
|
| 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 |
$33.67 |
| 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 |
$92.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.67
|
| 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 |
$89.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$97.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$77.45
|
| Rate for Payer: PHCS Commercial |
$107.76
|
| Rate for Payer: United Healthcare All Payer |
$98.78
|
|
|
STERILE WATER IRR 500mL BOTTLE
|
Facility
|
OP
|
$11.53
|
|
|
Service Code
|
NDC 264210110
|
| Hospital Charge Code |
25004358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$11.07 |
| Rate for Payer: Aetna Commercial |
$8.88
|
| Rate for Payer: Anthem Medicaid |
$3.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.99
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: First Health Commercial |
$10.95
|
| Rate for Payer: Humana Commercial |
$9.80
|
| Rate for Payer: Humana KY Medicaid |
$3.97
|
| Rate for Payer: Kentucky WC Medicaid |
$4.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.15
|
| Rate for Payer: Ohio Health Group HMO |
$8.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.96
|
| Rate for Payer: PHCS Commercial |
$11.07
|
| Rate for Payer: United Healthcare All Payer |
$10.15
|
|
|
STERILE WATER IRR 500mL BOTTLE
|
Facility
|
IP
|
$11.53
|
|
|
Service Code
|
NDC 264210110
|
| Hospital Charge Code |
25004358
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$11.07 |
| Rate for Payer: Aetna Commercial |
$8.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.99
|
| Rate for Payer: Cash Price |
$5.76
|
| Rate for Payer: Cigna Commercial |
$9.57
|
| Rate for Payer: First Health Commercial |
$10.95
|
| Rate for Payer: Humana Commercial |
$9.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.15
|
| Rate for Payer: Ohio Health Group HMO |
$8.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.96
|
| Rate for Payer: PHCS Commercial |
$11.07
|
| Rate for Payer: United Healthcare All Payer |
$10.15
|
|
|
STERILE WATER IRRIG 250ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990613922
|
| Hospital Charge Code |
25004355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
STERILE WATER IRRIG 250ML
|
Facility
|
IP
|
$22.25
|
|
|
Service Code
|
NDC 990613922
|
| Hospital Charge Code |
25004355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| 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 |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| 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 |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
|
STERILE WATER IRRIGAT 2000ML
|
Facility
|
OP
|
$121.90
|
|
|
Service Code
|
NDC 264738650
|
| Hospital Charge Code |
25003493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.57 |
| 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 |
$115.81
|
| Rate for Payer: Humana Commercial |
$103.61
|
| 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 |
$97.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.11
|
| Rate for Payer: PHCS Commercial |
$117.02
|
| Rate for Payer: United Healthcare All Payer |
$107.27
|
|
|
STERILE WATER IRRIGAT 2000ML
|
Facility
|
IP
|
$121.90
|
|
|
Service Code
|
NDC 264738650
|
| Hospital Charge Code |
25003493
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.57 |
| 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 |
$115.81
|
| Rate for Payer: Humana Commercial |
$103.61
|
| 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 |
$97.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.11
|
| Rate for Payer: PHCS Commercial |
$117.02
|
| Rate for Payer: United Healthcare All Payer |
$107.27
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
OP
|
$80.25
|
|
| Hospital Charge Code |
63600171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.07 |
| 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 |
$62.59
|
| 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 |
$65.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| 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 |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.37
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
IP
|
$80.25
|
|
| Hospital Charge Code |
63600171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Aetna Commercial |
$61.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.59
|
| 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 |
$65.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| 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 |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.37
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
OP
|
$80.25
|
|
| Hospital Charge Code |
636T0171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.07 |
| 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 |
$62.59
|
| 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 |
$65.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| 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 |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.37
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
OP
|
$80.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25004257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.07 |
| 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 |
$62.59
|
| 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 |
$65.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| 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 |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.37
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
IP
|
$80.25
|
|
|
Service Code
|
NDC 990799009
|
| Hospital Charge Code |
25004257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Aetna Commercial |
$61.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.59
|
| 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 |
$65.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| 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 |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.37
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Facility
|
IP
|
$80.25
|
|
| Hospital Charge Code |
636T0171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.07 |
| Max. Negotiated Rate |
$77.04 |
| Rate for Payer: Aetna Commercial |
$61.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.59
|
| 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 |
$65.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.07
|
| 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 |
$64.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.37
|
| Rate for Payer: PHCS Commercial |
$77.04
|
| Rate for Payer: United Healthcare All Payer |
$70.62
|
|
|
STERILE WATER IRRIGATIONBAG 1L
|
Professional
|
Both
|
$80.25
|
|
| Hospital Charge Code |
63600171
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.09 |
| Max. Negotiated Rate |
$56.17 |
| Rate for Payer: Cash Price |
$40.12
|
| Rate for Payer: Multiplan PHCS |
$48.15
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$56.17
|
| Rate for Payer: UHCCP Medicaid |
$28.09
|
|
|
STERILE WATER IRRIGATIONBAG 3L
|
Facility
|
OP
|
$86.82
|
|
|
Service Code
|
NDC 990797308
|
| Hospital Charge Code |
25004258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.05 |
| Max. Negotiated Rate |
$83.35 |
| Rate for Payer: Aetna Commercial |
$66.85
|
| Rate for Payer: Anthem Medicaid |
$29.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.72
|
| Rate for Payer: Cash Price |
$43.41
|
| Rate for Payer: Cigna Commercial |
$72.06
|
| Rate for Payer: First Health Commercial |
$82.48
|
| Rate for Payer: Humana Commercial |
$73.80
|
| Rate for Payer: Humana KY Medicaid |
$29.86
|
| Rate for Payer: Kentucky WC Medicaid |
$30.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.40
|
| Rate for Payer: Ohio Health Group HMO |
$65.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.91
|
| Rate for Payer: PHCS Commercial |
$83.35
|
| Rate for Payer: United Healthcare All Payer |
$76.40
|
|
|
STERILE WATER IRRIGATIONBAG 3L
|
Facility
|
IP
|
$86.82
|
|
|
Service Code
|
NDC 990797308
|
| Hospital Charge Code |
25004258
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.05 |
| Max. Negotiated Rate |
$83.35 |
| Rate for Payer: Aetna Commercial |
$66.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.72
|
| Rate for Payer: Cash Price |
$43.41
|
| Rate for Payer: Cigna Commercial |
$72.06
|
| Rate for Payer: First Health Commercial |
$82.48
|
| Rate for Payer: Humana Commercial |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$64.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.40
|
| Rate for Payer: Ohio Health Group HMO |
$65.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.91
|
| Rate for Payer: PHCS Commercial |
$83.35
|
| Rate for Payer: United Healthcare All Payer |
$76.40
|
|
|
STERIL WATER/IRRIGATIO 1000ML
|
Facility
|
OP
|
$22.25
|
|
|
Service Code
|
NDC 990713909
|
| Hospital Charge Code |
25003488
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.67 |
| 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 |
$18.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.67
|
| 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 |
$17.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.35
|
| Rate for Payer: PHCS Commercial |
$21.36
|
| Rate for Payer: United Healthcare All Payer |
$19.58
|
|
