|
BRIEF EMOTIONAL/BEHAV ASSMT(T
|
Facility
|
OP
|
$53.00
|
|
|
Service Code
|
HCPCS 96127
|
| Hospital Charge Code |
510T0048
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$18.23 |
| Max. Negotiated Rate |
$50.88 |
| Rate for Payer: Aetna Commercial |
$40.81
|
| Rate for Payer: Anthem Medicaid |
$18.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$41.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.96
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cash Price |
$26.50
|
| Rate for Payer: Cigna Commercial |
$43.99
|
| Rate for Payer: First Health Commercial |
$50.35
|
| Rate for Payer: Humana Commercial |
$45.05
|
| Rate for Payer: Humana KY Medicaid |
$18.23
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$18.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$43.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$46.64
|
| Rate for Payer: Ohio Health Group HMO |
$39.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$42.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.57
|
| Rate for Payer: PHCS Commercial |
$50.88
|
| Rate for Payer: United Healthcare All Payer |
$46.64
|
|
|
BRIGHTAMIN C
|
Facility
|
IP
|
$145.00
|
|
| Hospital Charge Code |
22200124
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$139.20 |
| Rate for Payer: Aetna Commercial |
$111.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.10
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$120.35
|
| Rate for Payer: First Health Commercial |
$137.75
|
| Rate for Payer: Humana Commercial |
$123.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.60
|
| Rate for Payer: Ohio Health Group HMO |
$108.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.05
|
| Rate for Payer: PHCS Commercial |
$139.20
|
| Rate for Payer: United Healthcare All Payer |
$127.60
|
|
|
BRIGHTAMIN C
|
Professional
|
Both
|
$145.00
|
|
| Hospital Charge Code |
22200124
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$50.75 |
| Max. Negotiated Rate |
$101.50 |
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Multiplan PHCS |
$87.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.50
|
| Rate for Payer: UHCCP Medicaid |
$50.75
|
|
|
BRIGHTAMIN C
|
Facility
|
OP
|
$145.00
|
|
| Hospital Charge Code |
22200124
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$43.50 |
| Max. Negotiated Rate |
$139.20 |
| Rate for Payer: Aetna Commercial |
$111.65
|
| Rate for Payer: Anthem Medicaid |
$49.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$113.10
|
| Rate for Payer: Cash Price |
$72.50
|
| Rate for Payer: Cigna Commercial |
$120.35
|
| Rate for Payer: First Health Commercial |
$137.75
|
| Rate for Payer: Humana Commercial |
$123.25
|
| Rate for Payer: Humana KY Medicaid |
$49.87
|
| Rate for Payer: Kentucky WC Medicaid |
$50.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$107.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.60
|
| Rate for Payer: Ohio Health Group HMO |
$108.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$116.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$126.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$100.05
|
| Rate for Payer: PHCS Commercial |
$139.20
|
| Rate for Payer: United Healthcare All Payer |
$127.60
|
|
|
BRIGHT NON-RETINOL SK BRIGHT
|
Professional
|
Both
|
$120.00
|
|
| Hospital Charge Code |
22200159
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
|
|
BRIGHT NON-RETINOL SK BRIGHT
|
Facility
|
IP
|
$120.00
|
|
| Hospital Charge Code |
22200159
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
BRIGHT NON-RETINOL SK BRIGHT
|
Facility
|
OP
|
$120.00
|
|
| Hospital Charge Code |
22200159
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
BRILINTA 60MG TABLET
|
Facility
|
IP
|
$24.75
|
|
|
Service Code
|
NDC 186077660
|
| Hospital Charge Code |
25003874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Aetna Commercial |
$19.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.30
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna Commercial |
$20.54
|
| Rate for Payer: First Health Commercial |
$23.51
|
| Rate for Payer: Humana Commercial |
$21.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.78
|
| Rate for Payer: Ohio Health Group HMO |
$18.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.08
|
| Rate for Payer: PHCS Commercial |
$23.76
|
| Rate for Payer: United Healthcare All Payer |
$21.78
|
|
|
BRILINTA 60MG TABLET
|
Facility
|
OP
|
$24.75
|
|
|
Service Code
|
NDC 186077660
|
| Hospital Charge Code |
25003874
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Aetna Commercial |
$19.06
|
| Rate for Payer: Anthem Medicaid |
$8.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.30
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna Commercial |
$20.54
|
| Rate for Payer: First Health Commercial |
$23.51
|
| Rate for Payer: Humana Commercial |
$21.04
|
| Rate for Payer: Humana KY Medicaid |
$8.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.78
|
| Rate for Payer: Ohio Health Group HMO |
$18.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.08
|
| Rate for Payer: PHCS Commercial |
$23.76
|
| Rate for Payer: United Healthcare All Payer |
$21.78
|
|
|
BRILINTA 90MG TABLET
|
Facility
|
IP
|
$24.75
|
|
|
Service Code
|
NDC 186077739
|
| Hospital Charge Code |
25000346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Aetna Commercial |
$19.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.30
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna Commercial |
$20.54
|
| Rate for Payer: First Health Commercial |
$23.51
|
| Rate for Payer: Humana Commercial |
$21.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.78
|
| Rate for Payer: Ohio Health Group HMO |
$18.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.08
|
| Rate for Payer: PHCS Commercial |
$23.76
|
| Rate for Payer: United Healthcare All Payer |
$21.78
|
|
|
BRILINTA 90MG TABLET
|
Facility
|
OP
|
$24.75
|
|
|
Service Code
|
NDC 186077739
|
| Hospital Charge Code |
25000346
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$23.76 |
| Rate for Payer: Aetna Commercial |
$19.06
|
| Rate for Payer: Anthem Medicaid |
$8.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.30
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: Cigna Commercial |
$20.54
|
| Rate for Payer: First Health Commercial |
$23.51
|
| Rate for Payer: Humana Commercial |
$21.04
|
| Rate for Payer: Humana KY Medicaid |
$8.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.78
|
| Rate for Payer: Ohio Health Group HMO |
$18.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.08
|
| Rate for Payer: PHCS Commercial |
$23.76
|
| Rate for Payer: United Healthcare All Payer |
$21.78
|
|
|
BRIMOIDINE 0.2% 5ML PER BOTTLE
|
Facility
|
IP
|
$81.11
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
25000198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$77.87 |
| Rate for Payer: Aetna Commercial |
$62.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.27
|
| Rate for Payer: Cash Price |
$40.56
|
| Rate for Payer: Cigna Commercial |
$67.32
|
| Rate for Payer: First Health Commercial |
$77.05
|
| Rate for Payer: Humana Commercial |
$68.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.38
|
| Rate for Payer: Ohio Health Group HMO |
$60.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.97
|
| Rate for Payer: PHCS Commercial |
$77.87
|
| Rate for Payer: United Healthcare All Payer |
$71.38
|
|
|
BRIMOIDINE 0.2% 5ML PER BOTTLE
|
Facility
|
OP
|
$81.11
|
|
|
Service Code
|
NDC 70069023101
|
| Hospital Charge Code |
25000198
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$77.87 |
| Rate for Payer: Aetna Commercial |
$62.45
|
| Rate for Payer: Anthem Medicaid |
$27.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.27
|
| Rate for Payer: Cash Price |
$40.56
|
| Rate for Payer: Cigna Commercial |
$67.32
|
| Rate for Payer: First Health Commercial |
$77.05
|
| Rate for Payer: Humana Commercial |
$68.94
|
| Rate for Payer: Humana KY Medicaid |
$27.89
|
| Rate for Payer: Kentucky WC Medicaid |
$28.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.38
|
| Rate for Payer: Ohio Health Group HMO |
$60.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.97
|
| Rate for Payer: PHCS Commercial |
$77.87
|
| Rate for Payer: United Healthcare All Payer |
$71.38
|
|
|
BRIVARACETAM 50mg SDV
|
Facility
|
IP
|
$344.06
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004432
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$103.22 |
| Max. Negotiated Rate |
$330.30 |
| Rate for Payer: Aetna Commercial |
$264.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$268.37
|
| Rate for Payer: Cash Price |
$172.03
|
| Rate for Payer: Cigna Commercial |
$285.57
|
| Rate for Payer: First Health Commercial |
$326.86
|
| Rate for Payer: Humana Commercial |
$292.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$253.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$302.77
|
| Rate for Payer: Ohio Health Group HMO |
$258.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.40
|
| Rate for Payer: PHCS Commercial |
$330.30
|
| Rate for Payer: United Healthcare All Payer |
$302.77
|
|
|
BRIVARACETAM 50mg SDV
|
Facility
|
OP
|
$344.06
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004432
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$103.22 |
| Max. Negotiated Rate |
$330.30 |
| Rate for Payer: Aetna Commercial |
$264.93
|
| Rate for Payer: Anthem Medicaid |
$118.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$268.37
|
| Rate for Payer: Cash Price |
$172.03
|
| Rate for Payer: Cigna Commercial |
$285.57
|
| Rate for Payer: First Health Commercial |
$326.86
|
| Rate for Payer: Humana Commercial |
$292.45
|
| Rate for Payer: Humana KY Medicaid |
$118.32
|
| Rate for Payer: Kentucky WC Medicaid |
$119.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$282.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$253.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$120.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$302.77
|
| Rate for Payer: Ohio Health Group HMO |
$258.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$275.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$237.40
|
| Rate for Payer: PHCS Commercial |
$330.30
|
| Rate for Payer: United Healthcare All Payer |
$302.77
|
|
|
BRNCHSC W/THER ASPIR 1ST
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
41000052
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$74.06 |
| Max. Negotiated Rate |
$377.41 |
| Rate for Payer: Aetna Commercial |
$268.31
|
| Rate for Payer: Ambetter Exchange |
$136.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$74.06
|
| Rate for Payer: Anthem Medicaid |
$197.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.39
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$243.04
|
| Rate for Payer: Healthspan PPO |
$377.41
|
| Rate for Payer: Humana Medicaid |
$197.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$206.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.05
|
| Rate for Payer: Molina Healthcare Passport |
$197.11
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.09
|
| Rate for Payer: UHCCP Medicaid |
$77.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.99
|
|
|
BRNCHSC W/THER ASPIR 1ST
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
41000052
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$100.50 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.15
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
BRNCHSC W/THER ASPIR 1ST
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
41000052
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$115.21 |
| Max. Negotiated Rate |
$2,230.73 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem Medicaid |
$115.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,593.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,230.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,151.06
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Humana KY Medicaid |
$115.21
|
| Rate for Payer: Humana Medicare Advantage |
$1,593.38
|
| Rate for Payer: Kentucky WC Medicaid |
$116.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,912.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.15
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
BRNCHSC W/THER ASPIR 1ST(P
|
Professional
|
Both
|
$335.00
|
|
|
Service Code
|
HCPCS 31645
|
| Hospital Charge Code |
410P0052
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$74.06 |
| Max. Negotiated Rate |
$377.41 |
| Rate for Payer: Aetna Commercial |
$268.31
|
| Rate for Payer: Ambetter Exchange |
$136.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$74.06
|
| Rate for Payer: Anthem Medicaid |
$197.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.39
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$243.04
|
| Rate for Payer: Healthspan PPO |
$377.41
|
| Rate for Payer: Humana Medicaid |
$197.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$206.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$201.05
|
| Rate for Payer: Molina Healthcare Passport |
$197.11
|
| Rate for Payer: Multiplan PHCS |
$201.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.09
|
| Rate for Payer: UHCCP Medicaid |
$77.76
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$199.08
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.99
|
|
|
BRNCHSC W/THER ASPIR SBSQ
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
HCPCS 31646
|
| Hospital Charge Code |
41000053
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$91.20 |
| Max. Negotiated Rate |
$291.84 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
BRNCHSC W/THER ASPIR SBSQ
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
HCPCS 31646
|
| Hospital Charge Code |
41000053
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$342.14 |
| Rate for Payer: Aetna Commercial |
$232.40
|
| Rate for Payer: Ambetter Exchange |
$132.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$71.64
|
| Rate for Payer: Anthem Medicaid |
$168.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$132.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$132.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$159.40
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$211.45
|
| Rate for Payer: Healthspan PPO |
$342.14
|
| Rate for Payer: Humana Medicaid |
$168.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$179.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$132.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.82
|
| Rate for Payer: Molina Healthcare Passport |
$168.45
|
| Rate for Payer: Multiplan PHCS |
$182.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$172.68
|
| Rate for Payer: UHCCP Medicaid |
$75.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$132.83
|
|
|
BRNCHSC W/THER ASPIR SBSQ
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
HCPCS 31646
|
| Hospital Charge Code |
41000053
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$502.31 |
| Rate for Payer: Aetna Commercial |
$234.08
|
| Rate for Payer: Anthem Medicaid |
$104.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$358.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$237.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$502.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$484.37
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$252.32
|
| Rate for Payer: First Health Commercial |
$288.80
|
| Rate for Payer: Humana Commercial |
$258.40
|
| Rate for Payer: Humana KY Medicaid |
$104.55
|
| Rate for Payer: Humana Medicare Advantage |
$358.79
|
| Rate for Payer: Kentucky WC Medicaid |
$105.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$249.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$224.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$430.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$106.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$267.52
|
| Rate for Payer: Ohio Health Group HMO |
$228.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$243.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.76
|
| Rate for Payer: PHCS Commercial |
$291.84
|
| Rate for Payer: United Healthcare All Payer |
$267.52
|
|
|
BRNCHSC W/THER ASPIR SBSQ(P
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
HCPCS 31646
|
| Hospital Charge Code |
410P0053
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$71.64 |
| Max. Negotiated Rate |
$342.14 |
| Rate for Payer: Aetna Commercial |
$232.40
|
| Rate for Payer: Ambetter Exchange |
$132.83
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$71.64
|
| Rate for Payer: Anthem Medicaid |
$168.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$132.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$132.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$159.40
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$211.45
|
| Rate for Payer: Healthspan PPO |
$342.14
|
| Rate for Payer: Humana Medicaid |
$168.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$179.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$132.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$171.82
|
| Rate for Payer: Molina Healthcare Passport |
$168.45
|
| Rate for Payer: Multiplan PHCS |
$182.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$172.68
|
| Rate for Payer: UHCCP Medicaid |
$75.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$132.83
|
|
|
BROCHE KIRSCHNER 1.5MM LG 150
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem Medicaid |
$13.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Humana KY Medicaid |
$13.07
|
| Rate for Payer: Kentucky WC Medicaid |
$13.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.22
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
|
BROCHE KIRSCHNER 1.5MM LG 150
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$36.48 |
| Rate for Payer: Aetna Commercial |
$29.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29.64
|
| Rate for Payer: Cash Price |
$19.00
|
| Rate for Payer: Cigna Commercial |
$31.54
|
| Rate for Payer: First Health Commercial |
$36.10
|
| Rate for Payer: Humana Commercial |
$32.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$33.44
|
| Rate for Payer: Ohio Health Group HMO |
$28.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.22
|
| Rate for Payer: PHCS Commercial |
$36.48
|
| Rate for Payer: United Healthcare All Payer |
$33.44
|
|
