|
X-RAY XM ESOPHAGUS 1CNTRST
|
Professional
|
Both
|
$544.00
|
|
|
Service Code
|
HCPCS 74220
|
| Hospital Charge Code |
32001024
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$29.47 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$130.72
|
| Rate for Payer: Ambetter Exchange |
$86.75
|
| Rate for Payer: Anthem Medicaid |
$72.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$86.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$86.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$104.10
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$110.36
|
| Rate for Payer: Healthspan PPO |
$122.49
|
| Rate for Payer: Humana Medicaid |
$72.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$86.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.65
|
| Rate for Payer: Molina Healthcare Passport |
$72.21
|
| Rate for Payer: Multiplan PHCS |
$326.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.78
|
| Rate for Payer: UHCCP Medicaid |
$190.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$86.75
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST
|
Facility
|
IP
|
$544.00
|
|
|
Service Code
|
HCPCS 74220
|
| Hospital Charge Code |
32001024
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$163.20 |
| Max. Negotiated Rate |
$522.24 |
| Rate for Payer: Aetna Commercial |
$418.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$424.32
|
| Rate for Payer: Cash Price |
$272.00
|
| Rate for Payer: Cigna Commercial |
$451.52
|
| Rate for Payer: First Health Commercial |
$516.80
|
| Rate for Payer: Humana Commercial |
$462.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$446.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$401.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$478.72
|
| Rate for Payer: Ohio Health Group HMO |
$408.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$473.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$375.36
|
| Rate for Payer: PHCS Commercial |
$522.24
|
| Rate for Payer: United Healthcare All Payer |
$478.72
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST (P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 74220
|
| Hospital Charge Code |
320P1024
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$130.72 |
| Rate for Payer: Aetna Commercial |
$130.72
|
| Rate for Payer: Ambetter Exchange |
$86.75
|
| Rate for Payer: Anthem Medicaid |
$72.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$86.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$86.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$104.10
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$110.36
|
| Rate for Payer: Healthspan PPO |
$122.49
|
| Rate for Payer: Humana Medicaid |
$72.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$86.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.65
|
| Rate for Payer: Molina Healthcare Passport |
$72.21
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.78
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$86.75
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST (T
|
Facility
|
OP
|
$469.00
|
|
|
Service Code
|
HCPCS 74220
|
| Hospital Charge Code |
320T1024
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$161.29 |
| Max. Negotiated Rate |
$450.24 |
| Rate for Payer: Aetna Commercial |
$361.13
|
| Rate for Payer: Anthem Medicaid |
$161.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: First Health Commercial |
$445.55
|
| Rate for Payer: Humana Commercial |
$398.65
|
| Rate for Payer: Humana KY Medicaid |
$161.29
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$162.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$384.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$346.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$164.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$412.72
|
| Rate for Payer: Ohio Health Group HMO |
$351.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$408.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.61
|
| Rate for Payer: PHCS Commercial |
$450.24
|
| Rate for Payer: United Healthcare All Payer |
$412.72
|
|
|
X-RAY XM ESOPHAGUS 1CNTRST (T
|
Facility
|
IP
|
$469.00
|
|
|
Service Code
|
HCPCS 74220
|
| Hospital Charge Code |
320T1024
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$140.70 |
| Max. Negotiated Rate |
$450.24 |
| Rate for Payer: Aetna Commercial |
$361.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.82
|
| Rate for Payer: Cash Price |
$234.50
|
| Rate for Payer: Cigna Commercial |
$389.27
|
| Rate for Payer: First Health Commercial |
$445.55
|
| Rate for Payer: Humana Commercial |
$398.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$384.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$346.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$412.72
|
| Rate for Payer: Ohio Health Group HMO |
$351.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$408.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$323.61
|
| Rate for Payer: PHCS Commercial |
$450.24
|
| Rate for Payer: United Healthcare All Payer |
$412.72
|
|
|
XYLCN2%+EPNEPHRIN1:200KMPF10ML
|
Facility
|
OP
|
$117.27
|
|
|
Service Code
|
NDC 63323048901
|
| Hospital Charge Code |
25003733
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.18 |
| Max. Negotiated Rate |
$112.58 |
| Rate for Payer: Aetna Commercial |
$90.30
|
| Rate for Payer: Anthem Medicaid |
$40.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.47
|
| Rate for Payer: Cash Price |
$58.63
|
| Rate for Payer: Cigna Commercial |
$97.33
|
| Rate for Payer: First Health Commercial |
$111.41
|
| Rate for Payer: Humana Commercial |
$99.68
|
| Rate for Payer: Humana KY Medicaid |
$40.33
|
| Rate for Payer: Kentucky WC Medicaid |
$40.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.20
|
| Rate for Payer: Ohio Health Group HMO |
$87.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.92
|
| Rate for Payer: PHCS Commercial |
$112.58
|
| Rate for Payer: United Healthcare All Payer |
$103.20
|
|
|
XYLCN2%+EPNEPHRIN1:200KMPF10ML
|
Facility
|
IP
|
$117.27
|
|
|
Service Code
|
NDC 63323048901
|
| Hospital Charge Code |
25003733
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.18 |
| Max. Negotiated Rate |
$112.58 |
| Rate for Payer: Aetna Commercial |
$90.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.47
|
| Rate for Payer: Cash Price |
$58.63
|
| Rate for Payer: Cigna Commercial |
$97.33
|
| Rate for Payer: First Health Commercial |
$111.41
|
| Rate for Payer: Humana Commercial |
$99.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.20
|
| Rate for Payer: Ohio Health Group HMO |
$87.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.92
|
| Rate for Payer: PHCS Commercial |
$112.58
|
| Rate for Payer: United Healthcare All Payer |
$103.20
|
|
|
XYLOCAI MPF 1%+EPI 1:200K 30mL
|
Facility
|
OP
|
$118.83
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.65 |
| Max. Negotiated Rate |
$114.08 |
| Rate for Payer: Aetna Commercial |
$91.50
|
| Rate for Payer: Anthem Medicaid |
$40.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.69
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cigna Commercial |
$98.63
|
| Rate for Payer: First Health Commercial |
$112.89
|
| Rate for Payer: Humana Commercial |
$101.01
|
| Rate for Payer: Humana KY Medicaid |
$40.87
|
| Rate for Payer: Kentucky WC Medicaid |
$41.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.57
|
| Rate for Payer: Ohio Health Group HMO |
$89.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.99
|
| Rate for Payer: PHCS Commercial |
$114.08
|
| Rate for Payer: United Healthcare All Payer |
$104.57
|
|
|
XYLOCAI MPF 1%+EPI 1:200K 30mL
|
Facility
|
IP
|
$118.83
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003622
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.65 |
| Max. Negotiated Rate |
$114.08 |
| Rate for Payer: Aetna Commercial |
$91.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.69
|
| Rate for Payer: Cash Price |
$59.42
|
| Rate for Payer: Cigna Commercial |
$98.63
|
| Rate for Payer: First Health Commercial |
$112.89
|
| Rate for Payer: Humana Commercial |
$101.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$97.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$104.57
|
| Rate for Payer: Ohio Health Group HMO |
$89.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$81.99
|
| Rate for Payer: PHCS Commercial |
$114.08
|
| Rate for Payer: United Healthcare All Payer |
$104.57
|
|
|
XYLOCAINE 1%+ EPI 1:100K(10ML)
|
Facility
|
IP
|
$79.47
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.84 |
| Max. Negotiated Rate |
$76.29 |
| Rate for Payer: Aetna Commercial |
$61.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Cash Price |
$39.74
|
| Rate for Payer: Cigna Commercial |
$65.96
|
| Rate for Payer: First Health Commercial |
$75.50
|
| Rate for Payer: Humana Commercial |
$67.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.93
|
| Rate for Payer: Ohio Health Group HMO |
$59.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.83
|
| Rate for Payer: PHCS Commercial |
$76.29
|
| Rate for Payer: United Healthcare All Payer |
$69.93
|
|
|
XYLOCAINE 1%+ EPI 1:100K(10ML)
|
Facility
|
OP
|
$79.47
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003619
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.84 |
| Max. Negotiated Rate |
$76.29 |
| Rate for Payer: Aetna Commercial |
$61.19
|
| Rate for Payer: Anthem Medicaid |
$27.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Cash Price |
$39.74
|
| Rate for Payer: Cigna Commercial |
$65.96
|
| Rate for Payer: First Health Commercial |
$75.50
|
| Rate for Payer: Humana Commercial |
$67.55
|
| Rate for Payer: Humana KY Medicaid |
$27.33
|
| Rate for Payer: Kentucky WC Medicaid |
$27.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.93
|
| Rate for Payer: Ohio Health Group HMO |
$59.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.83
|
| Rate for Payer: PHCS Commercial |
$76.29
|
| Rate for Payer: United Healthcare All Payer |
$69.93
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
IP
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
OP
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003630
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem Medicaid |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Humana KY Medicaid |
$26.95
|
| Rate for Payer: Kentucky WC Medicaid |
$27.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
OP
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
636T0106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem Medicaid |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Humana KY Medicaid |
$26.95
|
| Rate for Payer: Kentucky WC Medicaid |
$27.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
IP
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Professional
|
Both
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$54.87 |
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Multiplan PHCS |
$47.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.87
|
| Rate for Payer: UHCCP Medicaid |
$27.43
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
OP
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem Medicaid |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Humana KY Medicaid |
$26.95
|
| Rate for Payer: Kentucky WC Medicaid |
$27.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 1% 20ML
|
Facility
|
IP
|
$78.38
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
636T0106
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.14
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.06
|
| Rate for Payer: First Health Commercial |
$74.46
|
| Rate for Payer: Humana Commercial |
$66.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.46
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
25003631
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem Medicaid |
$27.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Humana KY Medicaid |
$27.64
|
| Rate for Payer: Kentucky WC Medicaid |
$27.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.46
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
636T0107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.46
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Professional
|
Both
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.13 |
| Max. Negotiated Rate |
$56.26 |
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Multiplan PHCS |
$48.22
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$56.26
|
| Rate for Payer: UHCCP Medicaid |
$28.13
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
636T0107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem Medicaid |
$27.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Humana KY Medicaid |
$27.64
|
| Rate for Payer: Kentucky WC Medicaid |
$27.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.46
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.46
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
|
XYLOCAINE/EPINEPHRINE 2% 20ML
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
63600107
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$77.16 |
| Rate for Payer: Aetna Commercial |
$61.88
|
| Rate for Payer: Anthem Medicaid |
$27.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.69
|
| Rate for Payer: Cash Price |
$40.19
|
| Rate for Payer: Cigna Commercial |
$66.71
|
| Rate for Payer: First Health Commercial |
$76.35
|
| Rate for Payer: Humana Commercial |
$68.31
|
| Rate for Payer: Humana KY Medicaid |
$27.64
|
| Rate for Payer: Kentucky WC Medicaid |
$27.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.73
|
| Rate for Payer: Ohio Health Group HMO |
$60.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.46
|
| Rate for Payer: PHCS Commercial |
$77.16
|
| Rate for Payer: United Healthcare All Payer |
$70.73
|
|
