|
CABLE 1.6MM*750MM COIL
|
Facility
|
IP
|
$3,369.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$437.97 |
| Max. Negotiated Rate |
$3,234.24 |
| Rate for Payer: Aetna Commercial |
$2,594.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,627.82
|
| Rate for Payer: Cash Price |
$1,684.50
|
| Rate for Payer: Cigna Commercial |
$2,796.27
|
| Rate for Payer: First Health Commercial |
$3,200.55
|
| Rate for Payer: Humana Commercial |
$2,863.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,762.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,486.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,964.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,526.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$673.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$437.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,044.39
|
| Rate for Payer: PHCS Commercial |
$3,234.24
|
| Rate for Payer: United Healthcare All Payer |
$2,964.72
|
|
|
CABLE 1.6MM*750MM COIL
|
Facility
|
OP
|
$3,369.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$437.97 |
| Max. Negotiated Rate |
$3,234.24 |
| Rate for Payer: Aetna Commercial |
$2,594.13
|
| Rate for Payer: Anthem Medicaid |
$1,158.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,627.82
|
| Rate for Payer: Cash Price |
$1,684.50
|
| Rate for Payer: Cigna Commercial |
$2,796.27
|
| Rate for Payer: First Health Commercial |
$3,200.55
|
| Rate for Payer: Humana Commercial |
$2,863.65
|
| Rate for Payer: Humana KY Medicaid |
$1,158.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,170.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,762.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,486.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,010.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,181.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,964.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,526.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$673.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$437.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,044.39
|
| Rate for Payer: PHCS Commercial |
$3,234.24
|
| Rate for Payer: United Healthcare All Payer |
$2,964.72
|
|
|
CABLE ASSY CRCLGE COCR 1.8X36
|
Facility
|
OP
|
$5,595.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.35 |
| Max. Negotiated Rate |
$5,371.20 |
| Rate for Payer: Aetna Commercial |
$4,308.15
|
| Rate for Payer: Anthem Medicaid |
$1,924.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,364.10
|
| Rate for Payer: Cash Price |
$2,797.50
|
| Rate for Payer: Cigna Commercial |
$4,643.85
|
| Rate for Payer: First Health Commercial |
$5,315.25
|
| Rate for Payer: Humana Commercial |
$4,755.75
|
| Rate for Payer: Humana KY Medicaid |
$1,924.12
|
| Rate for Payer: Kentucky WC Medicaid |
$1,943.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,587.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,129.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,678.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,962.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,923.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,196.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,734.45
|
| Rate for Payer: PHCS Commercial |
$5,371.20
|
| Rate for Payer: United Healthcare All Payer |
$4,923.60
|
|
|
CABLE ASSY CRCLGE COCR 1.8X36
|
Facility
|
IP
|
$5,595.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$727.35 |
| Max. Negotiated Rate |
$5,371.20 |
| Rate for Payer: Aetna Commercial |
$4,308.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,364.10
|
| Rate for Payer: Cash Price |
$2,797.50
|
| Rate for Payer: Cigna Commercial |
$4,643.85
|
| Rate for Payer: First Health Commercial |
$5,315.25
|
| Rate for Payer: Humana Commercial |
$4,755.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,587.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,129.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,678.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,923.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,196.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,119.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$727.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,734.45
|
| Rate for Payer: PHCS Commercial |
$5,371.20
|
| Rate for Payer: United Healthcare All Payer |
$4,923.60
|
|
|
CABLE MULTI LEAD TRIAL 3013
|
Facility
|
OP
|
$1,945.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$252.85 |
| Max. Negotiated Rate |
$1,867.20 |
| Rate for Payer: Aetna Commercial |
$1,497.65
|
| Rate for Payer: Anthem Medicaid |
$668.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.10
|
| Rate for Payer: Cash Price |
$972.50
|
| Rate for Payer: Cigna Commercial |
$1,614.35
|
| Rate for Payer: First Health Commercial |
$1,847.75
|
| Rate for Payer: Humana Commercial |
$1,653.25
|
| Rate for Payer: Humana KY Medicaid |
$668.89
|
| Rate for Payer: Kentucky WC Medicaid |
$675.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,594.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,435.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$682.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,711.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,458.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$602.95
|
| Rate for Payer: PHCS Commercial |
$1,867.20
|
| Rate for Payer: United Healthcare All Payer |
$1,711.60
|
|
|
CABLE MULTI LEAD TRIAL 3013
|
Facility
|
IP
|
$1,945.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$252.85 |
| Max. Negotiated Rate |
$1,867.20 |
| Rate for Payer: Aetna Commercial |
$1,497.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.10
|
| Rate for Payer: Cash Price |
$972.50
|
| Rate for Payer: Cigna Commercial |
$1,614.35
|
| Rate for Payer: First Health Commercial |
$1,847.75
|
| Rate for Payer: Humana Commercial |
$1,653.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,594.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,435.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,711.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,458.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$252.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$602.95
|
| Rate for Payer: PHCS Commercial |
$1,867.20
|
| Rate for Payer: United Healthcare All Payer |
$1,711.60
|
|
|
CABLE PERI-LOC SADDLE SHORT SS
|
Facility
|
OP
|
$1,895.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.39 |
| Max. Negotiated Rate |
$1,819.49 |
| Rate for Payer: Aetna Commercial |
$1,459.38
|
| Rate for Payer: Anthem Medicaid |
$651.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.33
|
| Rate for Payer: Cash Price |
$947.65
|
| Rate for Payer: Cigna Commercial |
$1,573.10
|
| Rate for Payer: First Health Commercial |
$1,800.54
|
| Rate for Payer: Humana Commercial |
$1,611.00
|
| Rate for Payer: Humana KY Medicaid |
$651.79
|
| Rate for Payer: Kentucky WC Medicaid |
$658.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,398.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$664.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,667.86
|
| Rate for Payer: Ohio Health Group HMO |
$1,421.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.54
|
| Rate for Payer: PHCS Commercial |
$1,819.49
|
| Rate for Payer: United Healthcare All Payer |
$1,667.86
|
|
|
CABLE PERI-LOC SADDLE SHORT SS
|
Facility
|
IP
|
$1,895.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.39 |
| Max. Negotiated Rate |
$1,819.49 |
| Rate for Payer: Aetna Commercial |
$1,459.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.33
|
| Rate for Payer: Cash Price |
$947.65
|
| Rate for Payer: Cigna Commercial |
$1,573.10
|
| Rate for Payer: First Health Commercial |
$1,800.54
|
| Rate for Payer: Humana Commercial |
$1,611.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,398.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,667.86
|
| Rate for Payer: Ohio Health Group HMO |
$1,421.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.54
|
| Rate for Payer: PHCS Commercial |
$1,819.49
|
| Rate for Payer: United Healthcare All Payer |
$1,667.86
|
|
|
CABLE PERI-LOC SADDLE TALL SS
|
Facility
|
IP
|
$1,895.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.39 |
| Max. Negotiated Rate |
$1,819.49 |
| Rate for Payer: Aetna Commercial |
$1,459.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.33
|
| Rate for Payer: Cash Price |
$947.65
|
| Rate for Payer: Cigna Commercial |
$1,573.10
|
| Rate for Payer: First Health Commercial |
$1,800.54
|
| Rate for Payer: Humana Commercial |
$1,611.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,398.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,667.86
|
| Rate for Payer: Ohio Health Group HMO |
$1,421.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.54
|
| Rate for Payer: PHCS Commercial |
$1,819.49
|
| Rate for Payer: United Healthcare All Payer |
$1,667.86
|
|
|
CABLE PERI-LOC SADDLE TALL SS
|
Facility
|
OP
|
$1,895.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.39 |
| Max. Negotiated Rate |
$1,819.49 |
| Rate for Payer: Aetna Commercial |
$1,459.38
|
| Rate for Payer: Anthem Medicaid |
$651.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.33
|
| Rate for Payer: Cash Price |
$947.65
|
| Rate for Payer: Cigna Commercial |
$1,573.10
|
| Rate for Payer: First Health Commercial |
$1,800.54
|
| Rate for Payer: Humana Commercial |
$1,611.00
|
| Rate for Payer: Humana KY Medicaid |
$651.79
|
| Rate for Payer: Kentucky WC Medicaid |
$658.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,398.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$664.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,667.86
|
| Rate for Payer: Ohio Health Group HMO |
$1,421.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.54
|
| Rate for Payer: PHCS Commercial |
$1,819.49
|
| Rate for Payer: United Healthcare All Payer |
$1,667.86
|
|
|
CABLE REM S-101-97-12
|
Facility
|
OP
|
$798.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$766.08 |
| Rate for Payer: Aetna Commercial |
$614.46
|
| Rate for Payer: Anthem Medicaid |
$274.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$622.44
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cigna Commercial |
$662.34
|
| Rate for Payer: First Health Commercial |
$758.10
|
| Rate for Payer: Humana Commercial |
$678.30
|
| Rate for Payer: Humana KY Medicaid |
$274.43
|
| Rate for Payer: Kentucky WC Medicaid |
$277.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$654.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$279.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$702.24
|
| Rate for Payer: Ohio Health Group HMO |
$598.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.38
|
| Rate for Payer: PHCS Commercial |
$766.08
|
| Rate for Payer: United Healthcare All Payer |
$702.24
|
|
|
CABLE REM S-101-97-12
|
Facility
|
IP
|
$798.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$766.08 |
| Rate for Payer: Aetna Commercial |
$614.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$622.44
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cigna Commercial |
$662.34
|
| Rate for Payer: First Health Commercial |
$758.10
|
| Rate for Payer: Humana Commercial |
$678.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$654.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$702.24
|
| Rate for Payer: Ohio Health Group HMO |
$598.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$247.38
|
| Rate for Payer: PHCS Commercial |
$766.08
|
| Rate for Payer: United Healthcare All Payer |
$702.24
|
|
|
CABLE SS 2.0*750MM
|
Facility
|
IP
|
$2,127.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$276.51 |
| Max. Negotiated Rate |
$2,041.92 |
| Rate for Payer: Aetna Commercial |
$1,637.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,659.06
|
| Rate for Payer: Cash Price |
$1,063.50
|
| Rate for Payer: Cigna Commercial |
$1,765.41
|
| Rate for Payer: First Health Commercial |
$2,020.65
|
| Rate for Payer: Humana Commercial |
$1,807.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,744.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,569.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$638.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,871.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,595.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$425.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$276.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$659.37
|
| Rate for Payer: PHCS Commercial |
$2,041.92
|
| Rate for Payer: United Healthcare All Payer |
$1,871.76
|
|
|
CABLE SS 2.0*750MM
|
Facility
|
OP
|
$2,127.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$276.51 |
| Max. Negotiated Rate |
$2,041.92 |
| Rate for Payer: Aetna Commercial |
$1,637.79
|
| Rate for Payer: Anthem Medicaid |
$731.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,659.06
|
| Rate for Payer: Cash Price |
$1,063.50
|
| Rate for Payer: Cigna Commercial |
$1,765.41
|
| Rate for Payer: First Health Commercial |
$2,020.65
|
| Rate for Payer: Humana Commercial |
$1,807.95
|
| Rate for Payer: Humana KY Medicaid |
$731.48
|
| Rate for Payer: Kentucky WC Medicaid |
$738.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,744.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,569.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$638.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$746.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,871.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,595.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$425.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$276.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$659.37
|
| Rate for Payer: PHCS Commercial |
$2,041.92
|
| Rate for Payer: United Healthcare All Payer |
$1,871.76
|
|
|
CAFFEINE CITRATE5MG 20MG/ML VL
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
25001954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$121.92 |
| Rate for Payer: Aetna Commercial |
$97.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.06
|
| Rate for Payer: Cash Price |
$63.50
|
| Rate for Payer: Cigna Commercial |
$105.41
|
| Rate for Payer: First Health Commercial |
$120.65
|
| Rate for Payer: Humana Commercial |
$107.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.76
|
| Rate for Payer: Ohio Health Group HMO |
$95.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.37
|
| Rate for Payer: PHCS Commercial |
$121.92
|
| Rate for Payer: United Healthcare All Payer |
$111.76
|
|
|
CAFFEINE CITRATE5MG 20MG/ML VL
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS J0706
|
| Hospital Charge Code |
25001954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$121.92 |
| Rate for Payer: Aetna Commercial |
$97.79
|
| Rate for Payer: Anthem Medicaid |
$43.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.06
|
| Rate for Payer: Cash Price |
$63.50
|
| Rate for Payer: Cigna Commercial |
$105.41
|
| Rate for Payer: First Health Commercial |
$120.65
|
| Rate for Payer: Humana Commercial |
$107.95
|
| Rate for Payer: Humana KY Medicaid |
$43.68
|
| Rate for Payer: Kentucky WC Medicaid |
$44.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.76
|
| Rate for Payer: Ohio Health Group HMO |
$95.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.37
|
| Rate for Payer: PHCS Commercial |
$121.92
|
| Rate for Payer: United Healthcare All Payer |
$111.76
|
|
|
CAFFEINE&NABENZOAT 500MG/2ML V
|
Facility
|
OP
|
$185.61
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$178.19 |
| Rate for Payer: Aetna Commercial |
$142.92
|
| Rate for Payer: Anthem Medicaid |
$63.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.78
|
| Rate for Payer: Cash Price |
$92.81
|
| Rate for Payer: Cigna Commercial |
$154.06
|
| Rate for Payer: First Health Commercial |
$176.33
|
| Rate for Payer: Humana Commercial |
$157.77
|
| Rate for Payer: Humana KY Medicaid |
$63.83
|
| Rate for Payer: Kentucky WC Medicaid |
$64.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.34
|
| Rate for Payer: Ohio Health Group HMO |
$139.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.54
|
| Rate for Payer: PHCS Commercial |
$178.19
|
| Rate for Payer: United Healthcare All Payer |
$163.34
|
|
|
CAFFEINE&NABENZOAT 500MG/2ML V
|
Facility
|
IP
|
$185.61
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25002915
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.13 |
| Max. Negotiated Rate |
$178.19 |
| Rate for Payer: Aetna Commercial |
$142.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.78
|
| Rate for Payer: Cash Price |
$92.81
|
| Rate for Payer: Cigna Commercial |
$154.06
|
| Rate for Payer: First Health Commercial |
$176.33
|
| Rate for Payer: Humana Commercial |
$157.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.34
|
| Rate for Payer: Ohio Health Group HMO |
$139.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.54
|
| Rate for Payer: PHCS Commercial |
$178.19
|
| Rate for Payer: United Healthcare All Payer |
$163.34
|
|
|
CALADRYL (CALAMINE/DIPHEN) 6OZ
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 904253321
|
| Hospital Charge Code |
25000361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna Commercial |
$0.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.09
|
| Rate for Payer: First Health Commercial |
$0.10
|
| Rate for Payer: Humana Commercial |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.10
|
| Rate for Payer: Ohio Health Group HMO |
$0.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
CALADRYL (CALAMINE/DIPHEN) 6OZ
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 904253321
|
| Hospital Charge Code |
25000361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna Commercial |
$0.08
|
| Rate for Payer: Anthem Medicaid |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna Commercial |
$0.09
|
| Rate for Payer: First Health Commercial |
$0.10
|
| Rate for Payer: Humana Commercial |
$0.09
|
| Rate for Payer: Humana KY Medicaid |
$0.04
|
| Rate for Payer: Kentucky WC Medicaid |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.10
|
| Rate for Payer: Ohio Health Group HMO |
$0.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Payer |
$0.10
|
|
|
CALAN SR 120 MG TABLET
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 68462029201
|
| Hospital Charge Code |
25000362
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
CALAN SR 120 MG TABLET
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 68462029201
|
| Hospital Charge Code |
25000362
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
CALAN (VERAPAMIL) 5MG/ 5MG/2ML
|
Facility
|
IP
|
$185.38
|
|
|
Service Code
|
NDC 70069027101
|
| Hospital Charge Code |
25002917
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$142.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.60
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cigna Commercial |
$153.87
|
| Rate for Payer: First Health Commercial |
$176.11
|
| Rate for Payer: Humana Commercial |
$157.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.13
|
| Rate for Payer: Ohio Health Group HMO |
$139.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.47
|
| Rate for Payer: PHCS Commercial |
$177.96
|
| Rate for Payer: United Healthcare All Payer |
$163.13
|
|
|
CALAN (VERAPAMIL) 5MG/ 5MG/2ML
|
Facility
|
OP
|
$185.38
|
|
|
Service Code
|
NDC 70069027101
|
| Hospital Charge Code |
25002917
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.10 |
| Max. Negotiated Rate |
$177.96 |
| Rate for Payer: Aetna Commercial |
$142.74
|
| Rate for Payer: Anthem Medicaid |
$63.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.60
|
| Rate for Payer: Cash Price |
$92.69
|
| Rate for Payer: Cigna Commercial |
$153.87
|
| Rate for Payer: First Health Commercial |
$176.11
|
| Rate for Payer: Humana Commercial |
$157.57
|
| Rate for Payer: Humana KY Medicaid |
$63.75
|
| Rate for Payer: Kentucky WC Medicaid |
$64.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.13
|
| Rate for Payer: Ohio Health Group HMO |
$139.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.47
|
| Rate for Payer: PHCS Commercial |
$177.96
|
| Rate for Payer: United Healthcare All Payer |
$163.13
|
|
|
CALCIMAR (CALCITONIN 400IU/2ML
|
Facility
|
IP
|
$4,881.00
|
|
|
Service Code
|
HCPCS J0630
|
| Hospital Charge Code |
25001914
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$634.53 |
| Max. Negotiated Rate |
$4,685.76 |
| Rate for Payer: Aetna Commercial |
$3,758.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,807.18
|
| Rate for Payer: Cash Price |
$2,440.50
|
| Rate for Payer: Cigna Commercial |
$4,051.23
|
| Rate for Payer: First Health Commercial |
$4,636.95
|
| Rate for Payer: Humana Commercial |
$4,148.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,002.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,602.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,464.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,295.28
|
| Rate for Payer: Ohio Health Group HMO |
$3,660.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$976.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$634.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,513.11
|
| Rate for Payer: PHCS Commercial |
$4,685.76
|
| Rate for Payer: United Healthcare All Payer |
$4,295.28
|
|
