|
ACOUSTIC REFLEX TESTING
|
Facility
|
IP
|
$89.00
|
|
|
Service Code
|
HCPCS 92568
|
| Hospital Charge Code |
47000014
|
|
Hospital Revenue Code
|
471
|
| Min. Negotiated Rate |
$26.70 |
| Max. Negotiated Rate |
$85.44 |
| Rate for Payer: Aetna Commercial |
$68.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.42
|
| Rate for Payer: Cash Price |
$44.50
|
| Rate for Payer: Cigna Commercial |
$73.87
|
| Rate for Payer: First Health Commercial |
$84.55
|
| Rate for Payer: Humana Commercial |
$75.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$72.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$65.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$78.32
|
| Rate for Payer: Ohio Health Group HMO |
$66.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$71.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$77.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.41
|
| Rate for Payer: PHCS Commercial |
$85.44
|
| Rate for Payer: United Healthcare All Payer |
$78.32
|
|
|
ACRO CLAV JTS W/WO WGT BIL
|
Facility
|
IP
|
$353.00
|
|
|
Service Code
|
HCPCS 73050
|
| Hospital Charge Code |
32000077
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$105.90 |
| Max. Negotiated Rate |
$338.88 |
| Rate for Payer: Aetna Commercial |
$271.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$275.34
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cigna Commercial |
$292.99
|
| Rate for Payer: First Health Commercial |
$335.35
|
| Rate for Payer: Humana Commercial |
$300.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$289.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$260.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$310.64
|
| Rate for Payer: Ohio Health Group HMO |
$264.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.57
|
| Rate for Payer: PHCS Commercial |
$338.88
|
| Rate for Payer: United Healthcare All Payer |
$310.64
|
|
|
ACRO CLAV JTS W/WO WGT BIL
|
Facility
|
OP
|
$353.00
|
|
|
Service Code
|
HCPCS 73050
|
| Hospital Charge Code |
32000077
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$338.88 |
| Rate for Payer: Aetna Commercial |
$271.81
|
| Rate for Payer: Anthem Medicaid |
$121.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$275.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cigna Commercial |
$292.99
|
| Rate for Payer: First Health Commercial |
$335.35
|
| Rate for Payer: Humana Commercial |
$300.05
|
| Rate for Payer: Humana KY Medicaid |
$121.40
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$122.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$289.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$260.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$123.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$310.64
|
| Rate for Payer: Ohio Health Group HMO |
$264.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$282.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$243.57
|
| Rate for Payer: PHCS Commercial |
$338.88
|
| Rate for Payer: United Healthcare All Payer |
$310.64
|
|
|
ACRO CLAV JTS W/WO WGT BIL
|
Professional
|
Both
|
$353.00
|
|
|
Service Code
|
HCPCS 73050
|
| Hospital Charge Code |
32000077
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$211.80 |
| Rate for Payer: Aetna Commercial |
$54.17
|
| Rate for Payer: Ambetter Exchange |
$26.23
|
| Rate for Payer: Anthem Medicaid |
$26.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.48
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cash Price |
$176.50
|
| Rate for Payer: Cigna Commercial |
$53.71
|
| Rate for Payer: Healthspan PPO |
$50.76
|
| Rate for Payer: Humana Medicaid |
$26.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.19
|
| Rate for Payer: Molina Healthcare Passport |
$26.66
|
| Rate for Payer: Multiplan PHCS |
$211.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.10
|
| Rate for Payer: UHCCP Medicaid |
$123.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.23
|
|
|
ACRO CLAV JTS W/WO WGT BIL(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 73050
|
| Hospital Charge Code |
320P0077
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.42 |
| Max. Negotiated Rate |
$54.17 |
| Rate for Payer: Aetna Commercial |
$54.17
|
| Rate for Payer: Ambetter Exchange |
$26.23
|
| Rate for Payer: Anthem Medicaid |
$26.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.48
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$53.71
|
| Rate for Payer: Healthspan PPO |
$50.76
|
| Rate for Payer: Humana Medicaid |
$26.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.23
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.19
|
| Rate for Payer: Molina Healthcare Passport |
$26.66
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.10
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.23
|
|
|
ACRO CLAV JTS W/WO WGT BIL(T
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
HCPCS 73050
|
| Hospital Charge Code |
320T0077
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$290.88 |
| Rate for Payer: Aetna Commercial |
$233.31
|
| Rate for Payer: Anthem Medicaid |
$104.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$236.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cigna Commercial |
$251.49
|
| Rate for Payer: First Health Commercial |
$287.85
|
| Rate for Payer: Humana Commercial |
$257.55
|
| Rate for Payer: Humana KY Medicaid |
$104.20
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$105.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$248.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$223.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$266.64
|
| Rate for Payer: Ohio Health Group HMO |
$227.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.07
|
| Rate for Payer: PHCS Commercial |
$290.88
|
| Rate for Payer: United Healthcare All Payer |
$266.64
|
|
|
ACRO CLAV JTS W/WO WGT BIL(T
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
HCPCS 73050
|
| Hospital Charge Code |
320T0077
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$90.90 |
| Max. Negotiated Rate |
$290.88 |
| Rate for Payer: Aetna Commercial |
$233.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$236.34
|
| Rate for Payer: Cash Price |
$151.50
|
| Rate for Payer: Cigna Commercial |
$251.49
|
| Rate for Payer: First Health Commercial |
$287.85
|
| Rate for Payer: Humana Commercial |
$257.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$248.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$223.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$266.64
|
| Rate for Payer: Ohio Health Group HMO |
$227.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$263.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.07
|
| Rate for Payer: PHCS Commercial |
$290.88
|
| Rate for Payer: United Healthcare All Payer |
$266.64
|
|
|
ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT CORACOACROMIAL LIGAMENT RELEASE
|
Facility
|
OP
|
$4,197.13
|
|
|
Service Code
|
CPT 23130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,997.95 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
|
|
ACTEMRA 1mg (162mg PFS)
|
Facility
|
IP
|
$6,402.71
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25003875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,920.81 |
| Max. Negotiated Rate |
$6,146.60 |
| Rate for Payer: Aetna Commercial |
$4,930.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,994.11
|
| Rate for Payer: Cash Price |
$3,201.36
|
| Rate for Payer: Cigna Commercial |
$5,314.25
|
| Rate for Payer: First Health Commercial |
$6,082.57
|
| Rate for Payer: Humana Commercial |
$5,442.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,250.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,725.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,920.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,634.38
|
| Rate for Payer: Ohio Health Group HMO |
$4,802.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,122.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,570.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,417.87
|
| Rate for Payer: PHCS Commercial |
$6,146.60
|
| Rate for Payer: United Healthcare All Payer |
$5,634.38
|
|
|
ACTEMRA 1mg (162mg PFS)
|
Facility
|
OP
|
$6,402.71
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25003875
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$6,146.60 |
| Rate for Payer: Aetna Commercial |
$4,930.09
|
| Rate for Payer: Anthem Medicaid |
$2,201.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,994.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.82
|
| Rate for Payer: Cash Price |
$3,201.36
|
| Rate for Payer: Cash Price |
$3,201.36
|
| Rate for Payer: Cigna Commercial |
$5,314.25
|
| Rate for Payer: First Health Commercial |
$6,082.57
|
| Rate for Payer: Humana Commercial |
$5,442.30
|
| Rate for Payer: Humana KY Medicaid |
$2,201.89
|
| Rate for Payer: Humana Medicare Advantage |
$5.79
|
| Rate for Payer: Kentucky WC Medicaid |
$2,224.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,250.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,725.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,246.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,634.38
|
| Rate for Payer: Ohio Health Group HMO |
$4,802.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,122.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,570.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,417.87
|
| Rate for Payer: PHCS Commercial |
$6,146.60
|
| Rate for Payer: United Healthcare All Payer |
$5,634.38
|
|
|
ACTEMRA 1MG [200MG/10ML VIAL]
|
Facility
|
IP
|
$7,237.11
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,171.13 |
| Max. Negotiated Rate |
$6,947.63 |
| Rate for Payer: Aetna Commercial |
$5,572.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.95
|
| Rate for Payer: Cash Price |
$3,618.55
|
| Rate for Payer: Cigna Commercial |
$6,006.80
|
| Rate for Payer: First Health Commercial |
$6,875.25
|
| Rate for Payer: Humana Commercial |
$6,151.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,171.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.66
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,789.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,296.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,993.61
|
| Rate for Payer: PHCS Commercial |
$6,947.63
|
| Rate for Payer: United Healthcare All Payer |
$6,368.66
|
|
|
ACTEMRA 1MG [200MG/10ML VIAL]
|
Facility
|
OP
|
$7,237.11
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002395
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$6,947.63 |
| Rate for Payer: Aetna Commercial |
$5,572.57
|
| Rate for Payer: Anthem Medicaid |
$2,488.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.82
|
| Rate for Payer: Cash Price |
$3,618.55
|
| Rate for Payer: Cash Price |
$3,618.55
|
| Rate for Payer: Cigna Commercial |
$6,006.80
|
| Rate for Payer: First Health Commercial |
$6,875.25
|
| Rate for Payer: Humana Commercial |
$6,151.54
|
| Rate for Payer: Humana KY Medicaid |
$2,488.84
|
| Rate for Payer: Humana Medicare Advantage |
$5.79
|
| Rate for Payer: Kentucky WC Medicaid |
$2,514.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,538.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.66
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,789.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,296.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,993.61
|
| Rate for Payer: PHCS Commercial |
$6,947.63
|
| Rate for Payer: United Healthcare All Payer |
$6,368.66
|
|
|
ACTEMRA 1MG [400MG/20ML VIAL]
|
Facility
|
OP
|
$14,474.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$13,895.25 |
| Rate for Payer: Aetna Commercial |
$11,145.15
|
| Rate for Payer: Anthem Medicaid |
$4,977.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,289.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.82
|
| Rate for Payer: Cash Price |
$7,237.11
|
| Rate for Payer: Cash Price |
$7,237.11
|
| Rate for Payer: Cigna Commercial |
$12,013.60
|
| Rate for Payer: First Health Commercial |
$13,750.51
|
| Rate for Payer: Humana Commercial |
$12,303.09
|
| Rate for Payer: Humana KY Medicaid |
$4,977.68
|
| Rate for Payer: Humana Medicare Advantage |
$5.79
|
| Rate for Payer: Kentucky WC Medicaid |
$5,028.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,868.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,681.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,077.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,737.31
|
| Rate for Payer: Ohio Health Group HMO |
$10,855.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,579.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,592.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,987.21
|
| Rate for Payer: PHCS Commercial |
$13,895.25
|
| Rate for Payer: United Healthcare All Payer |
$12,737.31
|
|
|
ACTEMRA 1MG [400MG/20ML VIAL]
|
Facility
|
IP
|
$14,474.22
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002396
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,342.27 |
| Max. Negotiated Rate |
$13,895.25 |
| Rate for Payer: Aetna Commercial |
$11,145.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,289.89
|
| Rate for Payer: Cash Price |
$7,237.11
|
| Rate for Payer: Cigna Commercial |
$12,013.60
|
| Rate for Payer: First Health Commercial |
$13,750.51
|
| Rate for Payer: Humana Commercial |
$12,303.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,868.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,681.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,342.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,737.31
|
| Rate for Payer: Ohio Health Group HMO |
$10,855.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,579.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,592.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,987.21
|
| Rate for Payer: PHCS Commercial |
$13,895.25
|
| Rate for Payer: United Healthcare All Payer |
$12,737.31
|
|
|
ACTEMRA 1MG[80MG/4ML VIAL]
|
Facility
|
IP
|
$2,894.82
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$868.45 |
| Max. Negotiated Rate |
$2,779.03 |
| Rate for Payer: Aetna Commercial |
$2,229.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,257.96
|
| Rate for Payer: Cash Price |
$1,447.41
|
| Rate for Payer: Cigna Commercial |
$2,402.70
|
| Rate for Payer: First Health Commercial |
$2,750.08
|
| Rate for Payer: Humana Commercial |
$2,460.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$868.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,315.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,518.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,997.43
|
| Rate for Payer: PHCS Commercial |
$2,779.03
|
| Rate for Payer: United Healthcare All Payer |
$2,547.44
|
|
|
ACTEMRA 1MG[80MG/4ML VIAL]
|
Facility
|
OP
|
$2,894.82
|
|
|
Service Code
|
HCPCS J3262
|
| Hospital Charge Code |
25002397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.79 |
| Max. Negotiated Rate |
$2,779.03 |
| Rate for Payer: Aetna Commercial |
$2,229.01
|
| Rate for Payer: Anthem Medicaid |
$995.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,257.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.82
|
| Rate for Payer: Cash Price |
$1,447.41
|
| Rate for Payer: Cash Price |
$1,447.41
|
| Rate for Payer: Cigna Commercial |
$2,402.70
|
| Rate for Payer: First Health Commercial |
$2,750.08
|
| Rate for Payer: Humana Commercial |
$2,460.60
|
| Rate for Payer: Humana KY Medicaid |
$995.53
|
| Rate for Payer: Humana Medicare Advantage |
$5.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,005.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,373.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,136.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,015.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,547.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,171.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,315.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,518.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,997.43
|
| Rate for Payer: PHCS Commercial |
$2,779.03
|
| Rate for Payer: United Healthcare All Payer |
$2,547.44
|
|
|
ACTH STIMULATION PANEL
|
Facility
|
OP
|
$275.00
|
|
|
Service Code
|
HCPCS 80400
|
| Hospital Charge Code |
30000175
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$32.62 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem Medicaid |
$32.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.62
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Humana KY Medicaid |
$32.62
|
| Rate for Payer: Humana Medicare Advantage |
$32.62
|
| Rate for Payer: Kentucky WC Medicaid |
$32.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
ACTH STIMULATION PANEL
|
Facility
|
IP
|
$275.00
|
|
|
Service Code
|
HCPCS 80400
|
| Hospital Charge Code |
30000175
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$82.50 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna Commercial |
$211.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$220.82
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$228.25
|
| Rate for Payer: First Health Commercial |
$261.25
|
| Rate for Payer: Humana Commercial |
$233.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$225.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$202.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$82.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$242.00
|
| Rate for Payer: Ohio Health Group HMO |
$206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.75
|
| Rate for Payer: PHCS Commercial |
$264.00
|
| Rate for Payer: United Healthcare All Payer |
$242.00
|
|
|
ACTIDOSE/AQUA(CHARC 50GM/240ML
|
Facility
|
OP
|
$35.92
|
|
|
Service Code
|
NDC 574052176
|
| Hospital Charge Code |
25000145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem Medicaid |
$12.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Humana KY Medicaid |
$12.35
|
| Rate for Payer: Kentucky WC Medicaid |
$12.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.78
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIDOSE/AQUA(CHARC 50GM/240ML
|
Facility
|
IP
|
$35.92
|
|
|
Service Code
|
NDC 574052176
|
| Hospital Charge Code |
25000145
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.78
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIDOSE/SORBITOL(C 50GM/240ML
|
Facility
|
IP
|
$35.92
|
|
|
Service Code
|
NDC 574052076
|
| Hospital Charge Code |
25000146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.78
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIDOSE/SORBITOL(C 50GM/240ML
|
Facility
|
OP
|
$35.92
|
|
|
Service Code
|
NDC 574052076
|
| Hospital Charge Code |
25000146
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.78 |
| Max. Negotiated Rate |
$34.48 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Anthem Medicaid |
$12.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28.02
|
| Rate for Payer: Cash Price |
$17.96
|
| Rate for Payer: Cigna Commercial |
$29.81
|
| Rate for Payer: First Health Commercial |
$34.12
|
| Rate for Payer: Humana Commercial |
$30.53
|
| Rate for Payer: Humana KY Medicaid |
$12.35
|
| Rate for Payer: Kentucky WC Medicaid |
$12.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.61
|
| Rate for Payer: Ohio Health Group HMO |
$26.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.78
|
| Rate for Payer: PHCS Commercial |
$34.48
|
| Rate for Payer: United Healthcare All Payer |
$31.61
|
|
|
ACTIGALL (URSODIOL) 300MG/1CAP
|
Facility
|
IP
|
$9.25
|
|
|
Service Code
|
NDC 527132601
|
| Hospital Charge Code |
25000147
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Aetna Commercial |
$7.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.21
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cigna Commercial |
$7.68
|
| Rate for Payer: First Health Commercial |
$8.79
|
| Rate for Payer: Humana Commercial |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.14
|
| Rate for Payer: Ohio Health Group HMO |
$6.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.38
|
| Rate for Payer: PHCS Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Payer |
$8.14
|
|
|
ACTIGALL (URSODIOL) 300MG/1CAP
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
NDC 527132601
|
| Hospital Charge Code |
25000147
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.77 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Aetna Commercial |
$7.12
|
| Rate for Payer: Anthem Medicaid |
$3.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.21
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cigna Commercial |
$7.68
|
| Rate for Payer: First Health Commercial |
$8.79
|
| Rate for Payer: Humana Commercial |
$7.86
|
| Rate for Payer: Humana KY Medicaid |
$3.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.14
|
| Rate for Payer: Ohio Health Group HMO |
$6.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.38
|
| Rate for Payer: PHCS Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Payer |
$8.14
|
|
|
ACTIGRAPHY 72 HRS TO 14 DAYS
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 95803
|
| Hospital Charge Code |
92000012
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
