|
BIOTENE ORAL RINSE 237ML
|
Facility
|
IP
|
$3.49
|
|
|
Service Code
|
NDC 48582080220
|
| Hospital Charge Code |
25004237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.72
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna Commercial |
$2.90
|
| Rate for Payer: First Health Commercial |
$3.32
|
| Rate for Payer: Humana Commercial |
$2.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.07
|
| Rate for Payer: Ohio Health Group HMO |
$2.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.41
|
| Rate for Payer: PHCS Commercial |
$3.35
|
| Rate for Payer: United Healthcare All Payer |
$3.07
|
|
|
BIOTENE ORAL RINSE 237ML
|
Facility
|
OP
|
$3.49
|
|
|
Service Code
|
NDC 48582080220
|
| Hospital Charge Code |
25004237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Anthem Medicaid |
$1.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.72
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna Commercial |
$2.90
|
| Rate for Payer: First Health Commercial |
$3.32
|
| Rate for Payer: Humana Commercial |
$2.97
|
| Rate for Payer: Humana KY Medicaid |
$1.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.07
|
| Rate for Payer: Ohio Health Group HMO |
$2.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.41
|
| Rate for Payer: PHCS Commercial |
$3.35
|
| Rate for Payer: United Healthcare All Payer |
$3.07
|
|
|
BIOTIN 1000 MCG TABLET
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 79854003985
|
| Hospital Charge Code |
25000338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
BIOTIN 1000 MCG TABLET
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 79854003985
|
| Hospital Charge Code |
25000338
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
BIOTRAK GUIDEWIRE .045*8 DT
|
Facility
|
IP
|
$466.25
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.88 |
| Max. Negotiated Rate |
$447.60 |
| Rate for Payer: Aetna Commercial |
$359.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$363.68
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cigna Commercial |
$386.99
|
| Rate for Payer: First Health Commercial |
$442.94
|
| Rate for Payer: Humana Commercial |
$396.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$382.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$139.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$410.30
|
| Rate for Payer: Ohio Health Group HMO |
$349.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$373.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$405.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$321.71
|
| Rate for Payer: PHCS Commercial |
$447.60
|
| Rate for Payer: United Healthcare All Payer |
$410.30
|
|
|
BIOTRAK GUIDEWIRE .045*8 DT
|
Facility
|
OP
|
$466.25
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.88 |
| Max. Negotiated Rate |
$447.60 |
| Rate for Payer: Aetna Commercial |
$359.01
|
| Rate for Payer: Anthem Medicaid |
$160.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$363.68
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cigna Commercial |
$386.99
|
| Rate for Payer: First Health Commercial |
$442.94
|
| Rate for Payer: Humana Commercial |
$396.31
|
| Rate for Payer: Humana KY Medicaid |
$160.34
|
| Rate for Payer: Kentucky WC Medicaid |
$161.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$382.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$344.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$139.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$163.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$410.30
|
| Rate for Payer: Ohio Health Group HMO |
$349.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$373.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$405.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$321.71
|
| Rate for Payer: PHCS Commercial |
$447.60
|
| Rate for Payer: United Healthcare All Payer |
$410.30
|
|
|
BIOTRAK GUIDEWIRE .045*8 ST
|
Facility
|
OP
|
$148.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$142.56 |
| Rate for Payer: Aetna Commercial |
$114.34
|
| Rate for Payer: Anthem Medicaid |
$51.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.83
|
| Rate for Payer: Cash Price |
$74.25
|
| Rate for Payer: Cigna Commercial |
$123.25
|
| Rate for Payer: First Health Commercial |
$141.07
|
| Rate for Payer: Humana Commercial |
$126.22
|
| Rate for Payer: Humana KY Medicaid |
$51.07
|
| Rate for Payer: Kentucky WC Medicaid |
$51.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.68
|
| Rate for Payer: Ohio Health Group HMO |
$111.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.47
|
| Rate for Payer: PHCS Commercial |
$142.56
|
| Rate for Payer: United Healthcare All Payer |
$130.68
|
|
|
BIOTRAK GUIDEWIRE .045*8 ST
|
Facility
|
IP
|
$148.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$44.55 |
| Max. Negotiated Rate |
$142.56 |
| Rate for Payer: Aetna Commercial |
$114.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.83
|
| Rate for Payer: Cash Price |
$74.25
|
| Rate for Payer: Cigna Commercial |
$123.25
|
| Rate for Payer: First Health Commercial |
$141.07
|
| Rate for Payer: Humana Commercial |
$126.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.68
|
| Rate for Payer: Ohio Health Group HMO |
$111.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.47
|
| Rate for Payer: PHCS Commercial |
$142.56
|
| Rate for Payer: United Healthcare All Payer |
$130.68
|
|
|
BIO-TRANSFIX IMPLANT 3*40
|
Facility
|
IP
|
$1,775.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
|
BIO-TRANSFIX IMPLANT 3*40
|
Facility
|
OP
|
$1,775.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem Medicaid |
$610.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Humana KY Medicaid |
$610.42
|
| Rate for Payer: Kentucky WC Medicaid |
$616.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$622.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
|
BIPAP 1ST DAY
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 94660
|
| Hospital Charge Code |
41000080
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$171.95 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem Medicaid |
$171.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$187.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$263.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$253.71
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Humana KY Medicaid |
$171.95
|
| Rate for Payer: Humana Medicare Advantage |
$187.93
|
| Rate for Payer: Kentucky WC Medicaid |
$173.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
BIPAP 1ST DAY
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 94660
|
| Hospital Charge Code |
41000080
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$19.21 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna Commercial |
$57.42
|
| Rate for Payer: Ambetter Exchange |
$34.50
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$19.21
|
| Rate for Payer: Anthem Medicaid |
$42.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$34.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$34.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.40
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$80.47
|
| Rate for Payer: Healthspan PPO |
$67.28
|
| Rate for Payer: Humana Medicaid |
$42.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$34.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.66
|
| Rate for Payer: Molina Healthcare Passport |
$42.80
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.85
|
| Rate for Payer: UHCCP Medicaid |
$20.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.50
|
|
|
BIPAP 1ST DAY
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 94660
|
| Hospital Charge Code |
41000080
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
BIPAP 1ST DAY(T
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 94660
|
| Hospital Charge Code |
410T0080
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$171.95 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem Medicaid |
$171.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$187.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$263.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$253.71
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Humana KY Medicaid |
$171.95
|
| Rate for Payer: Humana Medicare Advantage |
$187.93
|
| Rate for Payer: Kentucky WC Medicaid |
$173.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
BIPAP 1ST DAY(T
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 94660
|
| Hospital Charge Code |
410T0080
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
BIPOLAR PACE CATH 5FR FLO DIRC
|
Facility
|
OP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem Medicaid |
$590.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Humana KY Medicaid |
$590.82
|
| Rate for Payer: Kentucky WC Medicaid |
$596.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$602.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
|
BIPOLAR PACE CATH 5FR FLO DIRC
|
Facility
|
IP
|
$1,718.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$515.40 |
| Max. Negotiated Rate |
$1,649.28 |
| Rate for Payer: Aetna Commercial |
$1,322.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,340.04
|
| Rate for Payer: Cash Price |
$859.00
|
| Rate for Payer: Cigna Commercial |
$1,425.94
|
| Rate for Payer: First Health Commercial |
$1,632.10
|
| Rate for Payer: Humana Commercial |
$1,460.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,408.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,267.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$515.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,511.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,288.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,374.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,494.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,185.42
|
| Rate for Payer: PHCS Commercial |
$1,649.28
|
| Rate for Payer: United Healthcare All Payer |
$1,511.84
|
|
|
BISACODYL 10 MG SUPPO 10MG/1EA
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 71399846002
|
| Hospital Charge Code |
25000339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| 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 |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
BISACODYL 10 MG SUPPO 10MG/1EA
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 71399846002
|
| Hospital Charge Code |
25000339
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| 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 |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
BISMATROL 30ML ORAL SUSP
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 1490003908
|
| Hospital Charge Code |
25002896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
BISMATROL 30ML ORAL SUSP
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 1490003908
|
| Hospital Charge Code |
25002896
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
BIVIGAM 500MG [10% 5GM] VIAL
|
Facility
|
OP
|
$3,624.25
|
|
|
Service Code
|
HCPCS J1556
|
| Hospital Charge Code |
25002081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,087.28 |
| Max. Negotiated Rate |
$3,479.28 |
| Rate for Payer: Aetna Commercial |
$2,790.67
|
| Rate for Payer: Anthem Medicaid |
$1,246.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,826.91
|
| Rate for Payer: Cash Price |
$1,812.12
|
| Rate for Payer: Cigna Commercial |
$3,008.13
|
| Rate for Payer: First Health Commercial |
$3,443.04
|
| Rate for Payer: Humana Commercial |
$3,080.61
|
| Rate for Payer: Humana KY Medicaid |
$1,246.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1,259.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,971.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,674.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,087.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,271.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,189.34
|
| Rate for Payer: Ohio Health Group HMO |
$2,718.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,899.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,153.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,500.73
|
| Rate for Payer: PHCS Commercial |
$3,479.28
|
| Rate for Payer: United Healthcare All Payer |
$3,189.34
|
|
|
BIVIGAM 500MG [10% 5GM] VIAL
|
Facility
|
IP
|
$3,624.25
|
|
|
Service Code
|
HCPCS J1556
|
| Hospital Charge Code |
25002081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,087.28 |
| Max. Negotiated Rate |
$3,479.28 |
| Rate for Payer: Aetna Commercial |
$2,790.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,826.91
|
| Rate for Payer: Cash Price |
$1,812.12
|
| Rate for Payer: Cigna Commercial |
$3,008.13
|
| Rate for Payer: First Health Commercial |
$3,443.04
|
| Rate for Payer: Humana Commercial |
$3,080.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,971.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,674.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,087.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,189.34
|
| Rate for Payer: Ohio Health Group HMO |
$2,718.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,899.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,153.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,500.73
|
| Rate for Payer: PHCS Commercial |
$3,479.28
|
| Rate for Payer: United Healthcare All Payer |
$3,189.34
|
|
|
BKA TIBIA FIBULA
|
Facility
|
IP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27882
|
| Hospital Charge Code |
76100958
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$966.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
|
BKA TIBIA FIBULA
|
Facility
|
OP
|
$1,400.00
|
|
|
Service Code
|
HCPCS 27882
|
| Hospital Charge Code |
76100958
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.00 |
| Max. Negotiated Rate |
$1,344.00 |
| Rate for Payer: Aetna Commercial |
$1,078.00
|
| Rate for Payer: Anthem Medicaid |
$481.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,092.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cigna Commercial |
$1,162.00
|
| Rate for Payer: First Health Commercial |
$1,330.00
|
| Rate for Payer: Humana Commercial |
$1,190.00
|
| Rate for Payer: Humana KY Medicaid |
$481.46
|
| Rate for Payer: Kentucky WC Medicaid |
$486.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,148.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,033.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$420.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$491.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,232.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,050.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$966.00
|
| Rate for Payer: PHCS Commercial |
$1,344.00
|
| Rate for Payer: United Healthcare All Payer |
$1,232.00
|
|
