|
ZOSYN 1.125 GM (4.5 GM SOLN)
|
Facility
IP
|
$173.38
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25002313
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.54 |
| Max. Negotiated Rate |
$166.44 |
| Rate for Payer: Aetna Commercial |
$133.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$135.24
|
| Rate for Payer: Cash Price |
$86.69
|
| Rate for Payer: Cigna Commercial |
$143.91
|
| Rate for Payer: First Health Commercial |
$164.71
|
| Rate for Payer: Humana Commercial |
$147.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$142.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$52.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.57
|
| Rate for Payer: Ohio Health Group HMO |
$130.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.75
|
| Rate for Payer: PHCS Commercial |
$166.44
|
|
|
ZOSYN 2.25 GM/10 ML
|
Facility
IP
|
$42.53
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25004421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$40.83 |
| Rate for Payer: Aetna Commercial |
$32.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.17
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cigna Commercial |
$35.30
|
| Rate for Payer: First Health Commercial |
$40.40
|
| Rate for Payer: Humana Commercial |
$36.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.43
|
| Rate for Payer: Ohio Health Group HMO |
$31.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.18
|
| Rate for Payer: PHCS Commercial |
$40.83
|
|
|
ZOSYN 2.25 GM/10 ML
|
Facility
OP
|
$42.53
|
|
|
Service Code
|
HCPCS J2543
|
| Hospital Charge Code |
25004421
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.53 |
| Max. Negotiated Rate |
$40.83 |
| Rate for Payer: Aetna Commercial |
$32.75
|
| Rate for Payer: Anthem Medicaid |
$14.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33.17
|
| Rate for Payer: Cash Price |
$21.26
|
| Rate for Payer: Cigna Commercial |
$35.30
|
| Rate for Payer: First Health Commercial |
$40.40
|
| Rate for Payer: Humana Commercial |
$36.15
|
| Rate for Payer: Humana KY Medicaid |
$14.63
|
| Rate for Payer: Kentucky WC Medicaid |
$14.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$37.43
|
| Rate for Payer: Ohio Health Group HMO |
$31.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.18
|
| Rate for Payer: PHCS Commercial |
$40.83
|
| Rate for Payer: United Healthcare All Payer |
$37.43
|
|
|
ZOVIRAX (ACYCLOVIR) 200MG/1CAP
|
Facility
OP
|
$4.23
|
|
| Hospital Charge Code |
25001776
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
ZOVIRAX (ACYCLOVIR) 200MG/1CAP
|
Facility
IP
|
$4.23
|
|
| Hospital Charge Code |
25001776
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.06
|
|
|
ZOVIRAX(ACYCLOVIR)200MG 5ML
|
Facility
IP
|
$11.46
|
|
| Hospital Charge Code |
25003642
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.94
|
| Rate for Payer: Cash Price |
$5.73
|
| Rate for Payer: Cigna Commercial |
$9.51
|
| Rate for Payer: First Health Commercial |
$10.89
|
| Rate for Payer: Humana Commercial |
$9.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.08
|
| Rate for Payer: Ohio Health Group HMO |
$8.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.55
|
| Rate for Payer: PHCS Commercial |
$11.00
|
|
|
ZOVIRAX(ACYCLOVIR)200MG 5ML
|
Facility
OP
|
$11.46
|
|
| Hospital Charge Code |
25003642
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Anthem Medicaid |
$3.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.94
|
| Rate for Payer: Cash Price |
$5.73
|
| Rate for Payer: Cigna Commercial |
$9.51
|
| Rate for Payer: First Health Commercial |
$10.89
|
| Rate for Payer: Humana Commercial |
$9.74
|
| Rate for Payer: Humana KY Medicaid |
$3.94
|
| Rate for Payer: Kentucky WC Medicaid |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.08
|
| Rate for Payer: Ohio Health Group HMO |
$8.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.55
|
| Rate for Payer: PHCS Commercial |
$11.00
|
| Rate for Payer: United Healthcare All Payer |
$10.08
|
|
|
ZOVIRAX(ACYCLOVIR) 5% OIN 15GM
|
Facility
IP
|
$11.73
|
|
| Hospital Charge Code |
25001779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.15
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.14
|
| Rate for Payer: Humana Commercial |
$9.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.32
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.26
|
|
|
ZOVIRAX(ACYCLOVIR) 5% OIN 15GM
|
Facility
OP
|
$11.73
|
|
| Hospital Charge Code |
25001779
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$11.26 |
| Rate for Payer: Aetna Commercial |
$9.03
|
| Rate for Payer: Anthem Medicaid |
$4.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.15
|
| Rate for Payer: Cash Price |
$5.86
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.14
|
| Rate for Payer: Humana Commercial |
$9.97
|
| Rate for Payer: Humana KY Medicaid |
$4.03
|
| Rate for Payer: Kentucky WC Medicaid |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.32
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.26
|
| Rate for Payer: United Healthcare All Payer |
$10.32
|
|
|
ZOVIRAX (ACYCLOVIR) 800MG/1TAB
|
Facility
IP
|
$4.37
|
|
| Hospital Charge Code |
25001777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
|
|
ZOVIRAX (ACYCLOVIR) 800MG/1TAB
|
Facility
OP
|
$4.37
|
|
| Hospital Charge Code |
25001777
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.36
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cigna Commercial |
$3.63
|
| Rate for Payer: First Health Commercial |
$4.15
|
| Rate for Payer: Humana Commercial |
$3.71
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
ZR 12/14 TAPER FEM HD 22MM +4
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
|
ZR 12/14 TAPER FEM HD 22MM +4
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 22MM +8
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
|
ZR 12/14 TAPER FEM HD 22MM +8
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +0
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +0
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +4
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +4
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +8
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
|
ZR 12/14 TAPER FEM HD 26MM +8
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +0
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +0
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +4
|
Facility
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
ZR 12/14 TAPER FEM HD 28MM +4
|
Facility
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$195,234.43 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
|
