|
CAPSULORRHAPHY ANT PUTPLA/MAGN
|
Facility
|
IP
|
$2,215.00
|
|
|
Service Code
|
HCPCS 23450
|
| Hospital Charge Code |
76100462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$664.50 |
| 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 |
$1,772.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,927.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,528.35
|
| 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 |
76100462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$768.61 |
| Max. Negotiated Rate |
$1,552.63 |
| Rate for Payer: Aetna Commercial |
$1,419.70
|
| Rate for Payer: Ambetter Exchange |
$900.30
|
| Rate for Payer: Anthem Medicaid |
$768.61
|
| Rate for Payer: Buckeye Individual/Medicaid |
$900.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,080.36
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$900.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.30
|
| 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 |
$1,170.39
|
| Rate for Payer: UHCCP Medicaid |
$775.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$776.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$900.30
|
|
|
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 |
$1,552.63 |
| Rate for Payer: Aetna Commercial |
$1,419.70
|
| Rate for Payer: Ambetter Exchange |
$900.30
|
| Rate for Payer: Anthem Medicaid |
$768.61
|
| Rate for Payer: Buckeye Individual/Medicaid |
$900.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,080.36
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$900.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.30
|
| 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 |
$1,170.39
|
| Rate for Payer: UHCCP Medicaid |
$775.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$776.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$900.30
|
|
|
CAPSULORRHAPHY ANT PUTPLA/MAGN
|
Facility
|
OP
|
$2,215.00
|
|
|
Service Code
|
HCPCS 23450
|
| Hospital Charge Code |
76100462
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$761.74 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Aetna Commercial |
$1,705.55
|
| Rate for Payer: Anthem Medicaid |
$761.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,727.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| 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 |
$6,600.66
|
| 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 |
$7,920.79
|
| 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 |
$1,772.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,927.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,528.35
|
| 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 |
$1,656.54 |
| Rate for Payer: Aetna Commercial |
$1,515.10
|
| Rate for Payer: Ambetter Exchange |
$924.74
|
| Rate for Payer: Anthem Medicaid |
$883.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$924.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$924.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,109.69
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$924.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$924.74
|
| 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 |
$1,202.16
|
| Rate for Payer: UHCCP Medicaid |
$862.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$892.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$924.74
|
|
|
CAPSULORRHAPHY ANT WLABRAL RRP
|
Facility
|
OP
|
$2,465.00
|
|
|
Service Code
|
HCPCS 23455
|
| Hospital Charge Code |
76100463
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$847.71 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Aetna Commercial |
$1,898.05
|
| Rate for Payer: Anthem Medicaid |
$847.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,922.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| 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 |
$6,600.66
|
| 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 |
$7,920.79
|
| 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 |
$1,972.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,144.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,700.85
|
| 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 |
$1,656.54 |
| Rate for Payer: Aetna Commercial |
$1,515.10
|
| Rate for Payer: Ambetter Exchange |
$924.74
|
| Rate for Payer: Anthem Medicaid |
$883.62
|
| Rate for Payer: Buckeye Individual/Medicaid |
$924.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$924.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,109.69
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$924.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$924.74
|
| 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 |
$1,202.16
|
| Rate for Payer: UHCCP Medicaid |
$862.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$892.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$924.74
|
|
|
CAPSULORRHAPHY ANT WLABRAL RRP
|
Facility
|
IP
|
$2,465.00
|
|
|
Service Code
|
HCPCS 23455
|
| Hospital Charge Code |
76100463
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$739.50 |
| 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 |
$1,972.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,144.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,700.85
|
| Rate for Payer: PHCS Commercial |
$2,366.40
|
| Rate for Payer: United Healthcare All Payer |
$2,169.20
|
|
|
CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$4,197.13
|
|
|
Service Code
|
CPT 28270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,997.95 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
|
|
CARAFATE(SUCRALFATE)1GM/10ML
|
Facility
|
OP
|
$24.86
|
|
|
Service Code
|
NDC 50268074514
|
| Hospital Charge Code |
25000375
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.46 |
| 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 |
$19.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.15
|
| 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 |
$7.46 |
| 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 |
$19.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.15
|
| 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 |
$1.37 |
| 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 |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| 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 |
$1.37 |
| 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 |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
CARBAMAZEPINE (TEGRETOL)
|
Facility
|
OP
|
$90.00
|
|
|
Service Code
|
HCPCS 80156
|
| Hospital Charge Code |
30000021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem Medicaid |
$14.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.57
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| 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 |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
CARBAMAZEPINE (TEGRETOL)
|
Facility
|
IP
|
$90.00
|
|
|
Service Code
|
HCPCS 80156
|
| Hospital Charge Code |
30000021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$69.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.27
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna Commercial |
$74.70
|
| Rate for Payer: First Health Commercial |
$85.50
|
| Rate for Payer: Humana Commercial |
$76.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$73.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$79.20
|
| Rate for Payer: Ohio Health Group HMO |
$67.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.10
|
| Rate for Payer: PHCS Commercial |
$86.40
|
| Rate for Payer: United Healthcare All Payer |
$79.20
|
|
|
CARBIDOPA/LEVODOPAODT25/100MGT
|
Facility
|
IP
|
$5.08
|
|
|
Service Code
|
NDC 378505201
|
| Hospital Charge Code |
25002924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| 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 |
$4.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$4.88
|
| Rate for Payer: United Healthcare All Payer |
$4.47
|
|
|
CARBIDOPA/LEVODOPAODT25/100MGT
|
Facility
|
OP
|
$5.08
|
|
|
Service Code
|
NDC 378505201
|
| Hospital Charge Code |
25002924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.52 |
| 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 |
$4.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.51
|
| Rate for Payer: PHCS Commercial |
$4.88
|
| Rate for Payer: United Healthcare All Payer |
$4.47
|
|
|
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 |
$34.95 |
| 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 |
$93.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.39
|
| Rate for Payer: PHCS Commercial |
$111.85
|
| Rate for Payer: United Healthcare All Payer |
$102.53
|
|
|
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 |
$34.95 |
| 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 |
$93.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.39
|
| Rate for Payer: PHCS Commercial |
$111.85
|
| Rate for Payer: United Healthcare All Payer |
$102.53
|
|
|
CARBOCAINE(MEPIVACAINE) 1 30ML
|
Facility
|
OP
|
$115.57
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
25001923
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.67 |
| Max. Negotiated Rate |
$110.95 |
| Rate for Payer: Aetna Commercial |
$88.99
|
| Rate for Payer: Anthem Medicaid |
$39.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.14
|
| Rate for Payer: Cash Price |
$57.78
|
| Rate for Payer: Cigna Commercial |
$95.92
|
| Rate for Payer: First Health Commercial |
$109.79
|
| Rate for Payer: Humana Commercial |
$98.23
|
| Rate for Payer: Humana KY Medicaid |
$39.74
|
| Rate for Payer: Kentucky WC Medicaid |
$40.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.70
|
| Rate for Payer: Ohio Health Group HMO |
$86.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.74
|
| Rate for Payer: PHCS Commercial |
$110.95
|
| Rate for Payer: United Healthcare All Payer |
$101.70
|
|
|
CARBOCAINE(MEPIVACAINE) 1 30ML
|
Facility
|
IP
|
$115.57
|
|
|
Service Code
|
HCPCS J0670
|
| Hospital Charge Code |
25001923
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.67 |
| Max. Negotiated Rate |
$110.95 |
| Rate for Payer: Aetna Commercial |
$88.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.14
|
| Rate for Payer: Cash Price |
$57.78
|
| Rate for Payer: Cigna Commercial |
$95.92
|
| Rate for Payer: First Health Commercial |
$109.79
|
| Rate for Payer: Humana Commercial |
$98.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.70
|
| Rate for Payer: Ohio Health Group HMO |
$86.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.74
|
| Rate for Payer: PHCS Commercial |
$110.95
|
| Rate for Payer: United Healthcare All Payer |
$101.70
|
|
|
CARBON CONNECTING ROD 3MMX40MM
|
Facility
|
IP
|
$1,511.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$453.48 |
| Max. Negotiated Rate |
$1,451.14 |
| Rate for Payer: Aetna Commercial |
$1,163.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,179.05
|
| Rate for Payer: Cash Price |
$755.80
|
| Rate for Payer: Cigna Commercial |
$1,254.63
|
| Rate for Payer: First Health Commercial |
$1,436.02
|
| Rate for Payer: Humana Commercial |
$1,284.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,239.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,115.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,330.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,133.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,209.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,315.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,043.00
|
| Rate for Payer: PHCS Commercial |
$1,451.14
|
| Rate for Payer: United Healthcare All Payer |
$1,330.21
|
|
|
CARBON CONNECTING ROD 3MMX40MM
|
Facility
|
OP
|
$1,511.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$453.48 |
| Max. Negotiated Rate |
$1,451.14 |
| Rate for Payer: Aetna Commercial |
$1,163.93
|
| Rate for Payer: Anthem Medicaid |
$519.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,179.05
|
| Rate for Payer: Cash Price |
$755.80
|
| Rate for Payer: Cigna Commercial |
$1,254.63
|
| Rate for Payer: First Health Commercial |
$1,436.02
|
| Rate for Payer: Humana Commercial |
$1,284.86
|
| Rate for Payer: Humana KY Medicaid |
$519.84
|
| Rate for Payer: Kentucky WC Medicaid |
$525.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,239.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,115.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$530.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,330.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,133.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,209.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,315.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,043.00
|
| Rate for Payer: PHCS Commercial |
$1,451.14
|
| Rate for Payer: United Healthcare All Payer |
$1,330.21
|
|
|
CARBON CONNECTING ROD 3MMX50MM
|
Facility
|
OP
|
$1,511.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$453.48 |
| Max. Negotiated Rate |
$1,451.14 |
| Rate for Payer: Aetna Commercial |
$1,163.93
|
| Rate for Payer: Anthem Medicaid |
$519.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,179.05
|
| Rate for Payer: Cash Price |
$755.80
|
| Rate for Payer: Cigna Commercial |
$1,254.63
|
| Rate for Payer: First Health Commercial |
$1,436.02
|
| Rate for Payer: Humana Commercial |
$1,284.86
|
| Rate for Payer: Humana KY Medicaid |
$519.84
|
| Rate for Payer: Kentucky WC Medicaid |
$525.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,239.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,115.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$530.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,330.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,133.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,209.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,315.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,043.00
|
| Rate for Payer: PHCS Commercial |
$1,451.14
|
| Rate for Payer: United Healthcare All Payer |
$1,330.21
|
|
|
CARBON CONNECTING ROD 3MMX50MM
|
Facility
|
IP
|
$1,511.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$453.48 |
| Max. Negotiated Rate |
$1,451.14 |
| Rate for Payer: Aetna Commercial |
$1,163.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,179.05
|
| Rate for Payer: Cash Price |
$755.80
|
| Rate for Payer: Cigna Commercial |
$1,254.63
|
| Rate for Payer: First Health Commercial |
$1,436.02
|
| Rate for Payer: Humana Commercial |
$1,284.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,239.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,115.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$453.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,330.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,133.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,209.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,315.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,043.00
|
| Rate for Payer: PHCS Commercial |
$1,451.14
|
| Rate for Payer: United Healthcare All Payer |
$1,330.21
|
|
