|
CESARN DLV/POSTPART ATTMPT VBA
|
Facility
|
IP
|
$3,215.00
|
|
|
Service Code
|
HCPCS 59622
|
| Hospital Charge Code |
72000026
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$964.50 |
| Max. Negotiated Rate |
$3,086.40 |
| Rate for Payer: Aetna Commercial |
$2,475.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,507.70
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cigna Commercial |
$2,668.45
|
| Rate for Payer: First Health Commercial |
$3,054.25
|
| Rate for Payer: Humana Commercial |
$2,732.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,636.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,372.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,829.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,411.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,572.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,797.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,218.35
|
| Rate for Payer: PHCS Commercial |
$3,086.40
|
| Rate for Payer: United Healthcare All Payer |
$2,829.20
|
|
|
CESARN DLV/POSTPART ATTMPT VBA
|
Facility
|
OP
|
$3,215.00
|
|
|
Service Code
|
HCPCS 59622
|
| Hospital Charge Code |
72000026
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$964.50 |
| Max. Negotiated Rate |
$3,086.40 |
| Rate for Payer: Aetna Commercial |
$2,475.55
|
| Rate for Payer: Anthem Medicaid |
$1,105.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,507.70
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cigna Commercial |
$2,668.45
|
| Rate for Payer: First Health Commercial |
$3,054.25
|
| Rate for Payer: Humana Commercial |
$2,732.75
|
| Rate for Payer: Humana KY Medicaid |
$1,105.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,116.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,636.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,372.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,127.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,829.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,411.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,572.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,797.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,218.35
|
| Rate for Payer: PHCS Commercial |
$3,086.40
|
| Rate for Payer: United Healthcare All Payer |
$2,829.20
|
|
|
CESARN DLV/POSTPART ATTMPT VBA
|
Professional
|
Both
|
$3,215.00
|
|
|
Service Code
|
HCPCS 59622
|
| Hospital Charge Code |
72000026
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$1,978.50 |
| Rate for Payer: Aetna Commercial |
$1,951.85
|
| Rate for Payer: Ambetter Exchange |
$1,323.80
|
| Rate for Payer: Anthem Medicaid |
$900.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,323.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,323.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,588.56
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cigna Commercial |
$1,795.75
|
| Rate for Payer: Healthspan PPO |
$1,416.69
|
| Rate for Payer: Humana Medicaid |
$900.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,978.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,323.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,323.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$918.00
|
| Rate for Payer: Molina Healthcare Passport |
$900.00
|
| Rate for Payer: Multiplan PHCS |
$1,929.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,720.94
|
| Rate for Payer: UHCCP Medicaid |
$1,125.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$909.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,323.80
|
|
|
CESARN DLV/POSTPART ATTMPT VBA
|
Professional
|
Both
|
$3,215.00
|
|
|
Service Code
|
HCPCS 59622
|
| Hospital Charge Code |
720P0026
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$1,978.50 |
| Rate for Payer: Aetna Commercial |
$1,951.85
|
| Rate for Payer: Ambetter Exchange |
$1,323.80
|
| Rate for Payer: Anthem Medicaid |
$900.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,323.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,323.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,588.56
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cash Price |
$1,607.50
|
| Rate for Payer: Cigna Commercial |
$1,795.75
|
| Rate for Payer: Healthspan PPO |
$1,416.69
|
| Rate for Payer: Humana Medicaid |
$900.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,978.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,323.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,323.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$918.00
|
| Rate for Payer: Molina Healthcare Passport |
$900.00
|
| Rate for Payer: Multiplan PHCS |
$1,929.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,720.94
|
| Rate for Payer: UHCCP Medicaid |
$1,125.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$909.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,323.80
|
|
|
[C]ESGIC (COMBINATION) T 1TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 527169501
|
| Hospital Charge Code |
25000070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
[C]ESGIC (COMBINATION) T 1TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 527169501
|
| Hospital Charge Code |
25000070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
CESSJ THERAPY CATH REMOVAL
|
Facility
|
IP
|
$5,616.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
76101539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,684.80 |
| Max. Negotiated Rate |
$5,391.36 |
| Rate for Payer: Aetna Commercial |
$4,324.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,380.48
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cigna Commercial |
$4,661.28
|
| Rate for Payer: First Health Commercial |
$5,335.20
|
| Rate for Payer: Humana Commercial |
$4,773.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,605.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,144.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,684.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,942.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,212.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,492.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,885.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,875.04
|
| Rate for Payer: PHCS Commercial |
$5,391.36
|
| Rate for Payer: United Healthcare All Payer |
$4,942.08
|
|
|
CESSJ THERAPY CATH REMOVAL
|
Professional
|
Both
|
$5,616.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
76101539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.85 |
| Max. Negotiated Rate |
$3,369.60 |
| Rate for Payer: Ambetter Exchange |
$114.85
|
| Rate for Payer: Anthem Medicaid |
$118.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.82
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cigna Commercial |
$273.65
|
| Rate for Payer: Healthspan PPO |
$139.48
|
| Rate for Payer: Humana Medicaid |
$118.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$185.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$120.70
|
| Rate for Payer: Molina Healthcare Passport |
$118.33
|
| Rate for Payer: Multiplan PHCS |
$3,369.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.31
|
| Rate for Payer: UHCCP Medicaid |
$1,965.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$119.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.85
|
|
|
CESSJ THERAPY CATH REMOVAL
|
Facility
|
OP
|
$5,616.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
76101539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,931.34 |
| Max. Negotiated Rate |
$5,391.36 |
| Rate for Payer: Aetna Commercial |
$4,324.32
|
| Rate for Payer: Anthem Medicaid |
$1,931.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,380.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cash Price |
$2,808.00
|
| Rate for Payer: Cigna Commercial |
$4,661.28
|
| Rate for Payer: First Health Commercial |
$5,335.20
|
| Rate for Payer: Humana Commercial |
$4,773.60
|
| Rate for Payer: Humana KY Medicaid |
$1,931.34
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,951.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,605.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,144.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,970.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,942.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,212.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,492.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,885.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,875.04
|
| Rate for Payer: PHCS Commercial |
$5,391.36
|
| Rate for Payer: United Healthcare All Payer |
$4,942.08
|
|
|
CESSJ THERAPY CATH REMOVAL(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
761P1539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.85 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Ambetter Exchange |
$114.85
|
| Rate for Payer: Anthem Medicaid |
$118.33
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.82
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$273.65
|
| Rate for Payer: Healthspan PPO |
$139.48
|
| Rate for Payer: Humana Medicaid |
$118.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$185.50
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$120.70
|
| Rate for Payer: Molina Healthcare Passport |
$118.33
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.31
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$119.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.85
|
|
|
CESSJ THERAPY CATH REMOVAL(T
|
Facility
|
IP
|
$5,116.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
761T1539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,534.80 |
| Max. Negotiated Rate |
$4,911.36 |
| Rate for Payer: Aetna Commercial |
$3,939.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,990.48
|
| Rate for Payer: Cash Price |
$2,558.00
|
| Rate for Payer: Cigna Commercial |
$4,246.28
|
| Rate for Payer: First Health Commercial |
$4,860.20
|
| Rate for Payer: Humana Commercial |
$4,348.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,195.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,775.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,534.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,502.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,837.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,092.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,450.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,530.04
|
| Rate for Payer: PHCS Commercial |
$4,911.36
|
| Rate for Payer: United Healthcare All Payer |
$4,502.08
|
|
|
CESSJ THERAPY CATH REMOVAL(T
|
Facility
|
OP
|
$5,116.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
761T1539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,759.39 |
| Max. Negotiated Rate |
$4,911.36 |
| Rate for Payer: Aetna Commercial |
$3,939.32
|
| Rate for Payer: Anthem Medicaid |
$1,759.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,990.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Cash Price |
$2,558.00
|
| Rate for Payer: Cash Price |
$2,558.00
|
| Rate for Payer: Cigna Commercial |
$4,246.28
|
| Rate for Payer: First Health Commercial |
$4,860.20
|
| Rate for Payer: Humana Commercial |
$4,348.60
|
| Rate for Payer: Humana KY Medicaid |
$1,759.39
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,777.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,195.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,775.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,794.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,502.08
|
| Rate for Payer: Ohio Health Group HMO |
$3,837.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,092.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,450.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,530.04
|
| Rate for Payer: PHCS Commercial |
$4,911.36
|
| Rate for Payer: United Healthcare All Payer |
$4,502.08
|
|
|
CETACAINE (UD) SPRY (20GM KIT)
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 10223020103
|
| Hospital Charge Code |
25002936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$14.91 |
| Rate for Payer: Aetna Commercial |
$11.96
|
| Rate for Payer: Aetna Commercial |
$430.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.63
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cash Price |
$279.25
|
| Rate for Payer: Cigna Commercial |
$12.89
|
| Rate for Payer: Cigna Commercial |
$463.56
|
| Rate for Payer: First Health Commercial |
$530.58
|
| Rate for Payer: First Health Commercial |
$14.75
|
| Rate for Payer: Humana Commercial |
$474.73
|
| Rate for Payer: Humana Commercial |
$13.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$457.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.48
|
| Rate for Payer: Ohio Health Group HMO |
$11.65
|
| Rate for Payer: Ohio Health Group HMO |
$418.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$446.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.72
|
| Rate for Payer: PHCS Commercial |
$14.91
|
| Rate for Payer: PHCS Commercial |
$536.16
|
| Rate for Payer: United Healthcare All Payer |
$13.67
|
| Rate for Payer: United Healthcare All Payer |
$491.48
|
|
|
CETACAINE (UD) SPRY (20GM KIT)
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 10223020103
|
| Hospital Charge Code |
25002936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.66 |
| Max. Negotiated Rate |
$14.91 |
| Rate for Payer: Aetna Commercial |
$11.96
|
| Rate for Payer: Aetna Commercial |
$430.05
|
| Rate for Payer: Anthem Medicaid |
$5.34
|
| Rate for Payer: Anthem Medicaid |
$192.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.63
|
| Rate for Payer: Cash Price |
$7.76
|
| Rate for Payer: Cash Price |
$279.25
|
| Rate for Payer: Cigna Commercial |
$463.56
|
| Rate for Payer: Cigna Commercial |
$12.89
|
| Rate for Payer: First Health Commercial |
$530.58
|
| Rate for Payer: First Health Commercial |
$14.75
|
| Rate for Payer: Humana Commercial |
$13.20
|
| Rate for Payer: Humana Commercial |
$474.73
|
| Rate for Payer: Humana KY Medicaid |
$5.34
|
| Rate for Payer: Humana KY Medicaid |
$192.07
|
| Rate for Payer: Kentucky WC Medicaid |
$194.02
|
| Rate for Payer: Kentucky WC Medicaid |
$5.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$457.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$195.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$13.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.48
|
| Rate for Payer: Ohio Health Group HMO |
$11.65
|
| Rate for Payer: Ohio Health Group HMO |
$418.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$446.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$485.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.37
|
| Rate for Payer: PHCS Commercial |
$536.16
|
| Rate for Payer: PHCS Commercial |
$14.91
|
| Rate for Payer: United Healthcare All Payer |
$491.48
|
| Rate for Payer: United Healthcare All Payer |
$13.67
|
|
|
[C]FIORINAL (COMBINATION) 1TAB
|
Facility
|
OP
|
$9.10
|
|
|
Service Code
|
NDC 781227001
|
| Hospital Charge Code |
25000098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.28
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
|
[C]FIORINAL (COMBINATION) 1TAB
|
Facility
|
IP
|
$9.10
|
|
|
Service Code
|
NDC 781227001
|
| Hospital Charge Code |
25000098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.73 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.28
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
|
[C]FIORINAL W/CODEINE #3 1CAP
|
Facility
|
OP
|
$10.19
|
|
|
Service Code
|
NDC 69238199301
|
| Hospital Charge Code |
25000099
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.95
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.46
|
| Rate for Payer: First Health Commercial |
$9.68
|
| Rate for Payer: Humana Commercial |
$8.66
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.97
|
| Rate for Payer: Ohio Health Group HMO |
$7.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.03
|
| Rate for Payer: PHCS Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Payer |
$8.97
|
|
|
[C]FIORINAL W/CODEINE #3 1CAP
|
Facility
|
IP
|
$10.19
|
|
|
Service Code
|
NDC 69238199301
|
| Hospital Charge Code |
25000099
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.06 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.95
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.46
|
| Rate for Payer: First Health Commercial |
$9.68
|
| Rate for Payer: Humana Commercial |
$8.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.97
|
| Rate for Payer: Ohio Health Group HMO |
$7.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.03
|
| Rate for Payer: PHCS Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Payer |
$8.97
|
|
|
CG FUTURE BAND MODEL 638B 30MM
|
Facility
|
OP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem Medicaid |
$4,156.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Humana KY Medicaid |
$4,156.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE BAND MODEL 638B 30MM
|
Facility
|
IP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE BAND MODEL 638B 32MM
|
Facility
|
IP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE BAND MODEL 638B 32MM
|
Facility
|
OP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem Medicaid |
$4,156.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Humana KY Medicaid |
$4,156.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE BAND MODEL 638B 34MM
|
Facility
|
OP
|
$13,042.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem Medicaid |
$4,485.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Humana KY Medicaid |
$4,485.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,530.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,575.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
CG FUTURE BAND MODEL 638B 34MM
|
Facility
|
IP
|
$13,042.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
CG FUTURE BAND MODEL 638B 36MM
|
Facility
|
IP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
