|
CAPSULE EGD
|
Professional
|
Both
|
$1,803.00
|
|
|
Service Code
|
HCPCS 91110
|
| Hospital Charge Code |
75000006
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$249.71 |
| Max. Negotiated Rate |
$1,803.00 |
| Rate for Payer: Aetna Commercial |
$1,318.72
|
| Rate for Payer: Anthem Medicaid |
$656.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,803.00
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$1,219.64
|
| Rate for Payer: Healthspan PPO |
$1,079.15
|
| Rate for Payer: Humana Medicaid |
$656.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$249.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$669.54
|
| Rate for Payer: Molina Healthcare Passport |
$656.41
|
| Rate for Payer: Multiplan PHCS |
$1,081.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,262.10
|
| Rate for Payer: UHCCP Medicaid |
$631.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$662.97
|
|
|
CAPSULE EGD
|
Facility
|
OP
|
$1,803.00
|
|
|
Service Code
|
HCPCS 91110
|
| Hospital Charge Code |
75000006
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$234.39 |
| Max. Negotiated Rate |
$1,730.88 |
| Rate for Payer: Aetna Commercial |
$1,388.31
|
| Rate for Payer: Anthem Medicaid |
$620.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,406.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$1,496.49
|
| Rate for Payer: First Health Commercial |
$1,712.85
|
| Rate for Payer: Humana Commercial |
$1,532.55
|
| Rate for Payer: Humana KY Medicaid |
$620.05
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$626.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,478.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,330.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$632.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,586.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,352.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.93
|
| Rate for Payer: PHCS Commercial |
$1,730.88
|
| Rate for Payer: United Healthcare All Payer |
$1,586.64
|
|
|
CAPSULE EGD
|
Facility
|
IP
|
$1,803.00
|
|
|
Service Code
|
HCPCS 91110
|
| Hospital Charge Code |
75000006
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$234.39 |
| Max. Negotiated Rate |
$1,730.88 |
| Rate for Payer: Aetna Commercial |
$1,388.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,406.34
|
| Rate for Payer: Cash Price |
$901.50
|
| Rate for Payer: Cigna Commercial |
$1,496.49
|
| Rate for Payer: First Health Commercial |
$1,712.85
|
| Rate for Payer: Humana Commercial |
$1,532.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,478.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,330.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,586.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,352.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.93
|
| Rate for Payer: PHCS Commercial |
$1,730.88
|
| Rate for Payer: United Healthcare All Payer |
$1,586.64
|
|
|
CAPSULE EGD(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 91110
|
| Hospital Charge Code |
750P0006
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$148.75 |
| Max. Negotiated Rate |
$1,318.72 |
| Rate for Payer: Aetna Commercial |
$1,318.72
|
| Rate for Payer: Anthem Medicaid |
$656.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$425.00
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$1,219.64
|
| Rate for Payer: Healthspan PPO |
$1,079.15
|
| Rate for Payer: Humana Medicaid |
$656.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$249.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$669.54
|
| Rate for Payer: Molina Healthcare Passport |
$656.41
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$297.50
|
| Rate for Payer: UHCCP Medicaid |
$148.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$662.97
|
|
|
CAPSULE EGD(T
|
Facility
|
IP
|
$1,378.00
|
|
|
Service Code
|
HCPCS 91110
|
| Hospital Charge Code |
750T0006
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$179.14 |
| Max. Negotiated Rate |
$1,322.88 |
| Rate for Payer: Aetna Commercial |
$1,061.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,074.84
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cigna Commercial |
$1,143.74
|
| Rate for Payer: First Health Commercial |
$1,309.10
|
| Rate for Payer: Humana Commercial |
$1,171.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,129.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,016.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,212.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,033.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$179.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.18
|
| Rate for Payer: PHCS Commercial |
$1,322.88
|
| Rate for Payer: United Healthcare All Payer |
$1,212.64
|
|
|
CAPSULE EGD(T
|
Facility
|
OP
|
$1,378.00
|
|
|
Service Code
|
HCPCS 91110
|
| Hospital Charge Code |
750T0006
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$179.14 |
| Max. Negotiated Rate |
$1,322.88 |
| Rate for Payer: Aetna Commercial |
$1,061.06
|
| Rate for Payer: Anthem Medicaid |
$473.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,074.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cash Price |
$689.00
|
| Rate for Payer: Cigna Commercial |
$1,143.74
|
| Rate for Payer: First Health Commercial |
$1,309.10
|
| Rate for Payer: Humana Commercial |
$1,171.30
|
| Rate for Payer: Humana KY Medicaid |
$473.89
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$478.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,129.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,016.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$483.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,212.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,033.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$179.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$427.18
|
| Rate for Payer: PHCS Commercial |
$1,322.88
|
| Rate for Payer: United Healthcare All Payer |
$1,212.64
|
|
|
CAPSULORRHAPHY ANT PUTPLA/MAGN
|
Facility
|
IP
|
$2,215.00
|
|
|
Service Code
|
HCPCS 23450
|
| Hospital Charge Code |
76100462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.95 |
| Max. Negotiated Rate |
$2,126.40 |
| Rate for Payer: Aetna Commercial |
$1,705.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,727.70
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cigna Commercial |
$1,838.45
|
| Rate for Payer: First Health Commercial |
$2,104.25
|
| Rate for Payer: Humana Commercial |
$1,882.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,816.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,634.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$664.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,949.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,661.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$686.65
|
| Rate for Payer: PHCS Commercial |
$2,126.40
|
| Rate for Payer: United Healthcare All Payer |
$1,949.20
|
|
|
CAPSULORRHAPHY ANT PUTPLA/MAGN
|
Professional
|
Both
|
$2,215.00
|
|
|
Service Code
|
HCPCS 23450
|
| Hospital Charge Code |
761P0462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$768.61 |
| Max. Negotiated Rate |
$2,215.00 |
| Rate for Payer: Aetna Commercial |
$1,419.70
|
| Rate for Payer: Anthem Medicaid |
$768.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,215.00
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cigna Commercial |
$1,552.63
|
| Rate for Payer: Healthspan PPO |
$1,285.95
|
| Rate for Payer: Humana Medicaid |
$768.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,183.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$783.98
|
| Rate for Payer: Molina Healthcare Passport |
$768.61
|
| Rate for Payer: Multiplan PHCS |
$1,329.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,550.50
|
| Rate for Payer: UHCCP Medicaid |
$775.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$776.30
|
|
|
CAPSULORRHAPHY ANT PUTPLA/MAGN
|
Professional
|
Both
|
$2,215.00
|
|
|
Service Code
|
HCPCS 23450
|
| Hospital Charge Code |
76100462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$768.61 |
| Max. Negotiated Rate |
$2,215.00 |
| Rate for Payer: Aetna Commercial |
$1,419.70
|
| Rate for Payer: Anthem Medicaid |
$768.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,215.00
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cigna Commercial |
$1,552.63
|
| Rate for Payer: Healthspan PPO |
$1,285.95
|
| Rate for Payer: Humana Medicaid |
$768.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,183.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$783.98
|
| Rate for Payer: Molina Healthcare Passport |
$768.61
|
| Rate for Payer: Multiplan PHCS |
$1,329.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,550.50
|
| Rate for Payer: UHCCP Medicaid |
$775.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$776.30
|
|
|
CAPSULORRHAPHY ANT PUTPLA/MAGN
|
Facility
|
OP
|
$2,215.00
|
|
|
Service Code
|
HCPCS 23450
|
| Hospital Charge Code |
76100462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.95 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$1,705.55
|
| Rate for Payer: Anthem Medicaid |
$761.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,727.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cash Price |
$1,107.50
|
| Rate for Payer: Cigna Commercial |
$1,838.45
|
| Rate for Payer: First Health Commercial |
$2,104.25
|
| Rate for Payer: Humana Commercial |
$1,882.75
|
| Rate for Payer: Humana KY Medicaid |
$761.74
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$769.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,816.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,634.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$777.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,949.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,661.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$686.65
|
| Rate for Payer: PHCS Commercial |
$2,126.40
|
| Rate for Payer: United Healthcare All Payer |
$1,949.20
|
|
|
CAPSULORRHAPHY ANT WLABRAL RRP
|
Professional
|
Both
|
$2,465.00
|
|
|
Service Code
|
HCPCS 23455
|
| Hospital Charge Code |
761P0463
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$862.75 |
| Max. Negotiated Rate |
$2,465.00 |
| Rate for Payer: Aetna Commercial |
$1,515.10
|
| Rate for Payer: Anthem Medicaid |
$883.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,465.00
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cigna Commercial |
$1,656.54
|
| Rate for Payer: Healthspan PPO |
$1,372.35
|
| Rate for Payer: Humana Medicaid |
$883.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,257.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$901.29
|
| Rate for Payer: Molina Healthcare Passport |
$883.62
|
| Rate for Payer: Multiplan PHCS |
$1,479.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,725.50
|
| Rate for Payer: UHCCP Medicaid |
$862.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$892.46
|
|
|
CAPSULORRHAPHY ANT WLABRAL RRP
|
Facility
|
OP
|
$2,465.00
|
|
|
Service Code
|
HCPCS 23455
|
| Hospital Charge Code |
76100463
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$320.45 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$1,898.05
|
| Rate for Payer: Anthem Medicaid |
$847.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,922.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cigna Commercial |
$2,045.95
|
| Rate for Payer: First Health Commercial |
$2,341.75
|
| Rate for Payer: Humana Commercial |
$2,095.25
|
| Rate for Payer: Humana KY Medicaid |
$847.71
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$856.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,021.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,819.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$864.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,169.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,848.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$493.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$320.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$764.15
|
| Rate for Payer: PHCS Commercial |
$2,366.40
|
| Rate for Payer: United Healthcare All Payer |
$2,169.20
|
|
|
CAPSULORRHAPHY ANT WLABRAL RRP
|
Facility
|
IP
|
$2,465.00
|
|
|
Service Code
|
HCPCS 23455
|
| Hospital Charge Code |
76100463
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$320.45 |
| Max. Negotiated Rate |
$2,366.40 |
| Rate for Payer: Aetna Commercial |
$1,898.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,922.70
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cigna Commercial |
$2,045.95
|
| Rate for Payer: First Health Commercial |
$2,341.75
|
| Rate for Payer: Humana Commercial |
$2,095.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,021.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,819.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$739.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,169.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,848.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$493.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$320.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$764.15
|
| Rate for Payer: PHCS Commercial |
$2,366.40
|
| Rate for Payer: United Healthcare All Payer |
$2,169.20
|
|
|
CAPSULORRHAPHY ANT WLABRAL RRP
|
Professional
|
Both
|
$2,465.00
|
|
|
Service Code
|
HCPCS 23455
|
| Hospital Charge Code |
76100463
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$862.75 |
| Max. Negotiated Rate |
$2,465.00 |
| Rate for Payer: Aetna Commercial |
$1,515.10
|
| Rate for Payer: Anthem Medicaid |
$883.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,465.00
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cash Price |
$1,232.50
|
| Rate for Payer: Cigna Commercial |
$1,656.54
|
| Rate for Payer: Healthspan PPO |
$1,372.35
|
| Rate for Payer: Humana Medicaid |
$883.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,257.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$901.29
|
| Rate for Payer: Molina Healthcare Passport |
$883.62
|
| Rate for Payer: Multiplan PHCS |
$1,479.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,725.50
|
| Rate for Payer: UHCCP Medicaid |
$862.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$892.46
|
|
|
CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 28270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
CARAFATE(SUCRALFATE)1GM/10ML
|
Facility
|
OP
|
$24.86
|
|
|
Service Code
|
NDC 50268074514
|
| Hospital Charge Code |
25000375
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$23.87 |
| Rate for Payer: Aetna Commercial |
$19.14
|
| Rate for Payer: Anthem Medicaid |
$8.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.39
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cigna Commercial |
$20.63
|
| Rate for Payer: First Health Commercial |
$23.62
|
| Rate for Payer: Humana Commercial |
$21.13
|
| Rate for Payer: Humana KY Medicaid |
$8.55
|
| Rate for Payer: Kentucky WC Medicaid |
$8.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.88
|
| Rate for Payer: Ohio Health Group HMO |
$18.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.71
|
| Rate for Payer: PHCS Commercial |
$23.87
|
| Rate for Payer: United Healthcare All Payer |
$21.88
|
|
|
CARAFATE(SUCRALFATE)1GM/10ML
|
Facility
|
IP
|
$24.86
|
|
|
Service Code
|
NDC 50268074514
|
| Hospital Charge Code |
25000375
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$23.87 |
| Rate for Payer: Aetna Commercial |
$19.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.39
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cigna Commercial |
$20.63
|
| Rate for Payer: First Health Commercial |
$23.62
|
| Rate for Payer: Humana Commercial |
$21.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.88
|
| Rate for Payer: Ohio Health Group HMO |
$18.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.71
|
| Rate for Payer: PHCS Commercial |
$23.87
|
| Rate for Payer: United Healthcare All Payer |
$21.88
|
|
|
CARAFATE (SUCRALFATE) 1GM/1TAB
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
25000374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
CARAFATE (SUCRALFATE) 1GM/1TAB
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 60687069501
|
| Hospital Charge Code |
25000374
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
CARBAMAZEPINE (TEGRETOL)
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 80156
|
| Hospital Charge Code |
30000021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.26
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.35
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
CARBAMAZEPINE (TEGRETOL)
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 80156
|
| Hospital Charge Code |
30000021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$81.60 |
| Rate for Payer: Aetna Commercial |
$65.45
|
| Rate for Payer: Anthem Medicaid |
$14.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$68.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cash Price |
$42.50
|
| Rate for Payer: Cigna Commercial |
$70.55
|
| Rate for Payer: First Health Commercial |
$80.75
|
| Rate for Payer: Humana Commercial |
$72.25
|
| Rate for Payer: Humana KY Medicaid |
$14.57
|
| Rate for Payer: Humana Medicare Advantage |
$14.57
|
| Rate for Payer: Kentucky WC Medicaid |
$14.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$74.80
|
| Rate for Payer: Ohio Health Group HMO |
$63.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.35
|
| Rate for Payer: PHCS Commercial |
$81.60
|
| Rate for Payer: United Healthcare All Payer |
$74.80
|
|
|
CARBIDOPA/LEVODOPAODT25/100MGT
|
Facility
|
OP
|
$5.08
|
|
|
Service Code
|
NDC 378505201
|
| Hospital Charge Code |
25002924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.88 |
| Rate for Payer: Aetna Commercial |
$3.91
|
| Rate for Payer: Anthem Medicaid |
$1.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.96
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.83
|
| Rate for Payer: Humana Commercial |
$4.32
|
| Rate for Payer: Humana KY Medicaid |
$1.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.47
|
| Rate for Payer: Ohio Health Group HMO |
$3.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.88
|
| Rate for Payer: United Healthcare All Payer |
$4.47
|
|
|
CARBIDOPA/LEVODOPAODT25/100MGT
|
Facility
|
IP
|
$5.08
|
|
|
Service Code
|
NDC 378505201
|
| Hospital Charge Code |
25002924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.88 |
| Rate for Payer: Aetna Commercial |
$3.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.96
|
| Rate for Payer: Cash Price |
$2.54
|
| Rate for Payer: Cigna Commercial |
$4.22
|
| Rate for Payer: First Health Commercial |
$4.83
|
| Rate for Payer: Humana Commercial |
$4.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.47
|
| Rate for Payer: Ohio Health Group HMO |
$3.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.88
|
| Rate for Payer: United Healthcare All Payer |
$4.47
|
|
|
CARBOCAINE 2% VL [10 ML] 20MLV
|
Facility
|
OP
|
$116.51
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
25001922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$111.85 |
| Rate for Payer: Aetna Commercial |
$89.71
|
| Rate for Payer: Anthem Medicaid |
$40.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.88
|
| Rate for Payer: Cash Price |
$58.26
|
| Rate for Payer: Cigna Commercial |
$96.70
|
| Rate for Payer: First Health Commercial |
$110.68
|
| Rate for Payer: Humana Commercial |
$99.03
|
| Rate for Payer: Humana KY Medicaid |
$40.07
|
| Rate for Payer: Kentucky WC Medicaid |
$40.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.53
|
| Rate for Payer: Ohio Health Group HMO |
$87.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.12
|
| Rate for Payer: PHCS Commercial |
$111.85
|
| Rate for Payer: United Healthcare All Payer |
$102.53
|
|
|
CARBOCAINE 2% VL [10 ML] 20MLV
|
Facility
|
IP
|
$116.51
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
25001922
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.15 |
| Max. Negotiated Rate |
$111.85 |
| Rate for Payer: Aetna Commercial |
$89.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.88
|
| Rate for Payer: Cash Price |
$58.26
|
| Rate for Payer: Cigna Commercial |
$96.70
|
| Rate for Payer: First Health Commercial |
$110.68
|
| Rate for Payer: Humana Commercial |
$99.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.53
|
| Rate for Payer: Ohio Health Group HMO |
$87.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.12
|
| Rate for Payer: PHCS Commercial |
$111.85
|
| Rate for Payer: United Healthcare All Payer |
$102.53
|
|
