|
TX TIBSHFT FX IMD IMP &/CERCLA
|
Professional
|
Both
|
$2,006.00
|
|
|
Service Code
|
HCPCS 27759
|
| Hospital Charge Code |
761P0927
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$702.10 |
| Max. Negotiated Rate |
$2,006.00 |
| Rate for Payer: Aetna Commercial |
$1,496.64
|
| Rate for Payer: Anthem Medicaid |
$792.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,006.00
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cigna Commercial |
$1,630.43
|
| Rate for Payer: Healthspan PPO |
$1,355.63
|
| Rate for Payer: Humana Medicaid |
$792.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,250.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$808.05
|
| Rate for Payer: Molina Healthcare Passport |
$792.21
|
| Rate for Payer: Multiplan PHCS |
$1,203.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,404.20
|
| Rate for Payer: UHCCP Medicaid |
$702.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$800.13
|
|
|
TYLENOL 325MG SUPPOSITORY
|
Facility
|
IP
|
$9.02
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
25001610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.04
|
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cigna Commercial |
$7.49
|
| Rate for Payer: First Health Commercial |
$8.57
|
| Rate for Payer: Humana Commercial |
$7.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.94
|
| Rate for Payer: Ohio Health Group HMO |
$6.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.80
|
| Rate for Payer: PHCS Commercial |
$8.66
|
| Rate for Payer: United Healthcare All Payer |
$7.94
|
|
|
TYLENOL 325MG SUPPOSITORY
|
Facility
|
OP
|
$9.02
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
25001610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.04
|
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cigna Commercial |
$7.49
|
| Rate for Payer: First Health Commercial |
$8.57
|
| Rate for Payer: Humana Commercial |
$7.67
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.94
|
| Rate for Payer: Ohio Health Group HMO |
$6.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.80
|
| Rate for Payer: PHCS Commercial |
$8.66
|
| Rate for Payer: United Healthcare All Payer |
$7.94
|
|
|
TYLENOL (ACETAMIN) 325MG/1TAB
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
25001798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
TYLENOL (ACETAMIN) 325MG/1TAB
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
25001798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
TYLENOL(ACETAMIN) 65 650MG/1EA
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 45802073033
|
| Hospital Charge Code |
25001617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
TYLENOL(ACETAMIN) 65 650MG/1EA
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 45802073033
|
| Hospital Charge Code |
25001617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.36
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
TYLENOL(ACETAMINO 650MG/20.3ML
|
Facility
|
OP
|
$10.03
|
|
|
Service Code
|
NDC 121197100
|
| Hospital Charge Code |
25001618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna Commercial |
$7.72
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.82
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.32
|
| Rate for Payer: First Health Commercial |
$9.53
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.83
|
| Rate for Payer: Ohio Health Group HMO |
$7.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.63
|
| Rate for Payer: United Healthcare All Payer |
$8.83
|
|
|
TYLENOL(ACETAMINO 650MG/20.3ML
|
Facility
|
IP
|
$10.03
|
|
|
Service Code
|
NDC 121197100
|
| Hospital Charge Code |
25001618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna Commercial |
$7.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.82
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.32
|
| Rate for Payer: First Health Commercial |
$9.53
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.83
|
| Rate for Payer: Ohio Health Group HMO |
$7.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$9.63
|
| Rate for Payer: United Healthcare All Payer |
$8.83
|
|
|
TYLENOL(ACETAMINOPHE 120MG/1EA
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
25001620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
TYLENOL(ACETAMINOPHE 120MG/1EA
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 45802073230
|
| Hospital Charge Code |
25001620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
TYLENOL EQ 40MG/1.25ML ORL SOL
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 121197100
|
| Hospital Charge Code |
25003548
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
TYLENOL EQ 40MG/1.25ML ORL SOL
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 121197100
|
| Hospital Charge Code |
25003548
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.16 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.11
|
| Rate for Payer: Humana Commercial |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.81
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.16
|
| Rate for Payer: United Healthcare All Payer |
$3.81
|
|
|
TYLENOL ES (ACETAMI 500MG/1TAB
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 904673061
|
| Hospital Charge Code |
25001616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
TYLENOL ES (ACETAMI 500MG/1TAB
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 904673061
|
| Hospital Charge Code |
25001616
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna Commercial |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna Commercial |
$0.03
|
| Rate for Payer: First Health Commercial |
$0.04
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.04
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH
|
Facility
|
OP
|
$1,846.31
|
|
|
Service Code
|
CPT 69610
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,318.79 |
| Max. Negotiated Rate |
$1,846.31 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,318.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,846.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,780.37
|
| Rate for Payer: Humana Medicare Advantage |
$1,318.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.55
|
|
|
TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION
|
Facility
|
OP
|
$7,089.80
|
|
|
Service Code
|
CPT 69631
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$5,064.14 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
|
|
TYMPANOPLASTY W/O MASTOIDECTOM
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 69631
|
| Hospital Charge Code |
76102430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$325.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$775.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
TYMPANOPLASTY W/O MASTOIDECTOM
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 69631
|
| Hospital Charge Code |
76102430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$325.00 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Humana KY Medicaid |
$859.75
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$868.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$325.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$775.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
TYMPANOPLASTY W/O MASTOIDECTOM
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 69631
|
| Hospital Charge Code |
76102430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$647.12 |
| Max. Negotiated Rate |
$2,500.00 |
| Rate for Payer: Aetna Commercial |
$1,245.18
|
| Rate for Payer: Anthem Medicaid |
$647.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,500.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,212.73
|
| Rate for Payer: Healthspan PPO |
$1,104.53
|
| Rate for Payer: Humana Medicaid |
$647.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,124.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$660.06
|
| Rate for Payer: Molina Healthcare Passport |
$647.12
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,750.00
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$653.59
|
|
|
TYMPANOPLASTY W/O MASTOIDECTOM
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 69631
|
| Hospital Charge Code |
761P2430
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$647.12 |
| Max. Negotiated Rate |
$2,500.00 |
| Rate for Payer: Aetna Commercial |
$1,245.18
|
| Rate for Payer: Anthem Medicaid |
$647.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,500.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,212.73
|
| Rate for Payer: Healthspan PPO |
$1,104.53
|
| Rate for Payer: Humana Medicaid |
$647.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,124.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$660.06
|
| Rate for Payer: Molina Healthcare Passport |
$647.12
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,750.00
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$653.59
|
|
|
TYMPANOSTOMY
|
Facility
|
IP
|
$4,422.00
|
|
|
Service Code
|
HCPCS 69436
|
| Hospital Charge Code |
76102421
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$574.86 |
| Max. Negotiated Rate |
$4,245.12 |
| Rate for Payer: Aetna Commercial |
$3,404.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,449.16
|
| Rate for Payer: Cash Price |
$2,211.00
|
| Rate for Payer: Cigna Commercial |
$3,670.26
|
| Rate for Payer: First Health Commercial |
$4,200.90
|
| Rate for Payer: Humana Commercial |
$3,758.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,626.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,263.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,326.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,891.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,316.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$884.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,370.82
|
| Rate for Payer: PHCS Commercial |
$4,245.12
|
| Rate for Payer: United Healthcare All Payer |
$3,891.36
|
|
|
TYMPANOSTOMY
|
Professional
|
Both
|
$4,422.00
|
|
|
Service Code
|
HCPCS 69436
|
| Hospital Charge Code |
76102421
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.45 |
| Max. Negotiated Rate |
$4,422.00 |
| Rate for Payer: Aetna Commercial |
$235.42
|
| Rate for Payer: Anthem Medicaid |
$122.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,422.00
|
| Rate for Payer: Cash Price |
$2,211.00
|
| Rate for Payer: Cash Price |
$2,211.00
|
| Rate for Payer: Cigna Commercial |
$240.52
|
| Rate for Payer: Healthspan PPO |
$208.83
|
| Rate for Payer: Humana Medicaid |
$122.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$207.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.90
|
| Rate for Payer: Molina Healthcare Passport |
$122.45
|
| Rate for Payer: Multiplan PHCS |
$2,653.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,095.40
|
| Rate for Payer: UHCCP Medicaid |
$1,547.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.67
|
|
|
TYMPANOSTOMY
|
Facility
|
OP
|
$4,422.00
|
|
|
Service Code
|
HCPCS 69436
|
| Hospital Charge Code |
76102421
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$574.86 |
| Max. Negotiated Rate |
$4,245.12 |
| Rate for Payer: Aetna Commercial |
$3,404.94
|
| Rate for Payer: Anthem Medicaid |
$1,520.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,318.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,449.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,846.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,780.37
|
| Rate for Payer: Cash Price |
$2,211.00
|
| Rate for Payer: Cash Price |
$2,211.00
|
| Rate for Payer: Cigna Commercial |
$3,670.26
|
| Rate for Payer: First Health Commercial |
$4,200.90
|
| Rate for Payer: Humana Commercial |
$3,758.70
|
| Rate for Payer: Humana KY Medicaid |
$1,520.73
|
| Rate for Payer: Humana Medicare Advantage |
$1,318.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,536.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,626.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,263.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,551.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,891.36
|
| Rate for Payer: Ohio Health Group HMO |
$3,316.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$884.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$574.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,370.82
|
| Rate for Payer: PHCS Commercial |
$4,245.12
|
| Rate for Payer: United Healthcare All Payer |
$3,891.36
|
|
|
TYMPANOSTOMY(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 69436
|
| Hospital Charge Code |
761P2421
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.45 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$235.42
|
| Rate for Payer: Anthem Medicaid |
$122.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$240.52
|
| Rate for Payer: Healthspan PPO |
$208.83
|
| Rate for Payer: Humana Medicaid |
$122.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$207.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$124.90
|
| Rate for Payer: Molina Healthcare Passport |
$122.45
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$123.67
|
|
