|
CIPRO(CIPROFLOXACIN 750MG/1TAB
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
NDC 143992950
|
| Hospital Charge Code |
25000422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna Commercial |
$3.48
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.75
|
| Rate for Payer: First Health Commercial |
$4.29
|
| Rate for Payer: Humana Commercial |
$3.84
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.98
|
| Rate for Payer: Ohio Health Group HMO |
$3.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.12
|
| Rate for Payer: PHCS Commercial |
$4.34
|
| Rate for Payer: United Healthcare All Payer |
$3.98
|
|
|
CIPRODEX OTIC DROPS
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 43598032675
|
| Hospital Charge Code |
25000423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna Commercial |
$2.74
|
| Rate for Payer: Anthem Medicaid |
$1.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.78
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Cigna Commercial |
$2.95
|
| Rate for Payer: First Health Commercial |
$3.38
|
| Rate for Payer: Humana Commercial |
$3.03
|
| Rate for Payer: Humana KY Medicaid |
$1.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.13
|
| Rate for Payer: Ohio Health Group HMO |
$2.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.46
|
| Rate for Payer: PHCS Commercial |
$3.42
|
| Rate for Payer: United Healthcare All Payer |
$3.13
|
|
|
CIPRODEX OTIC DROPS
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 43598032675
|
| Hospital Charge Code |
25000423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.07 |
| Max. Negotiated Rate |
$3.42 |
| Rate for Payer: Aetna Commercial |
$2.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.78
|
| Rate for Payer: Cash Price |
$1.78
|
| Rate for Payer: Cigna Commercial |
$2.95
|
| Rate for Payer: First Health Commercial |
$3.38
|
| Rate for Payer: Humana Commercial |
$3.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.13
|
| Rate for Payer: Ohio Health Group HMO |
$2.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.46
|
| Rate for Payer: PHCS Commercial |
$3.42
|
| Rate for Payer: United Healthcare All Payer |
$3.13
|
|
|
CIPROFLOXACIN 0.3%EYEDROP(5ML)
|
Facility
|
OP
|
$0.89
|
|
|
Service Code
|
NDC 69315030805
|
| Hospital Charge Code |
25002941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna Commercial |
$0.69
|
| Rate for Payer: Anthem Medicaid |
$0.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna Commercial |
$0.74
|
| Rate for Payer: First Health Commercial |
$0.85
|
| Rate for Payer: Humana Commercial |
$0.76
|
| Rate for Payer: Humana KY Medicaid |
$0.31
|
| Rate for Payer: Kentucky WC Medicaid |
$0.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.78
|
| Rate for Payer: Ohio Health Group HMO |
$0.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.61
|
| Rate for Payer: PHCS Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Payer |
$0.78
|
|
|
CIPROFLOXACIN 0.3%EYEDROP(5ML)
|
Facility
|
IP
|
$0.89
|
|
|
Service Code
|
NDC 69315030805
|
| Hospital Charge Code |
25002941
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna Commercial |
$0.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Cash Price |
$0.44
|
| Rate for Payer: Cigna Commercial |
$0.74
|
| Rate for Payer: First Health Commercial |
$0.85
|
| Rate for Payer: Humana Commercial |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.78
|
| Rate for Payer: Ohio Health Group HMO |
$0.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.61
|
| Rate for Payer: PHCS Commercial |
$0.85
|
| Rate for Payer: United Healthcare All Payer |
$0.78
|
|
|
CIPROFLOXACN HCL OPTH SOL 0.3%
|
Facility
|
OP
|
$23.00
|
|
| Hospital Charge Code |
25002939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
CIPROFLOXACN HCL OPTH SOL 0.3%
|
Facility
|
IP
|
$23.00
|
|
| Hospital Charge Code |
25002939
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
CIPROHC(CIPROFLOXACIN)OTICSUSP
|
Facility
|
IP
|
$4.85
|
|
|
Service Code
|
NDC 66758008770
|
| Hospital Charge Code |
25000419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
CIPROHC(CIPROFLOXACIN)OTICSUSP
|
Facility
|
OP
|
$4.85
|
|
|
Service Code
|
NDC 66758008770
|
| Hospital Charge Code |
25000419
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
CIRCUM 28 DAYS OR OLDER
|
Facility
|
OP
|
$6,653.28
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
76102132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$6,387.15 |
| Rate for Payer: Aetna Commercial |
$5,123.03
|
| Rate for Payer: Anthem Medicaid |
$2,288.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,189.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$3,326.64
|
| Rate for Payer: Cash Price |
$3,326.64
|
| Rate for Payer: Cigna Commercial |
$5,522.22
|
| Rate for Payer: First Health Commercial |
$6,320.62
|
| Rate for Payer: Humana Commercial |
$5,655.29
|
| Rate for Payer: Humana KY Medicaid |
$2,288.06
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,311.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,455.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,910.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,333.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,854.89
|
| Rate for Payer: Ohio Health Group HMO |
$4,989.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,322.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,788.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,590.76
|
| Rate for Payer: PHCS Commercial |
$6,387.15
|
| Rate for Payer: United Healthcare All Payer |
$5,854.89
|
|
|
CIRCUM 28 DAYS OR OLDER
|
Professional
|
Both
|
$6,653.28
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
76102132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$158.28 |
| Max. Negotiated Rate |
$3,991.97 |
| Rate for Payer: Aetna Commercial |
$319.78
|
| Rate for Payer: Ambetter Exchange |
$187.06
|
| Rate for Payer: Anthem Medicaid |
$158.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$187.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$187.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$224.47
|
| Rate for Payer: Cash Price |
$3,326.64
|
| Rate for Payer: Cash Price |
$3,326.64
|
| Rate for Payer: Cigna Commercial |
$283.19
|
| Rate for Payer: Healthspan PPO |
$309.63
|
| Rate for Payer: Humana Medicaid |
$158.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$268.26
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$187.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$161.45
|
| Rate for Payer: Molina Healthcare Passport |
$158.28
|
| Rate for Payer: Multiplan PHCS |
$3,991.97
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$243.18
|
| Rate for Payer: UHCCP Medicaid |
$2,328.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$159.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$187.06
|
|
|
CIRCUM 28 DAYS OR OLDER
|
Facility
|
IP
|
$6,653.28
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
76102132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,995.98 |
| Max. Negotiated Rate |
$6,387.15 |
| Rate for Payer: Aetna Commercial |
$5,123.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,189.56
|
| Rate for Payer: Cash Price |
$3,326.64
|
| Rate for Payer: Cigna Commercial |
$5,522.22
|
| Rate for Payer: First Health Commercial |
$6,320.62
|
| Rate for Payer: Humana Commercial |
$5,655.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,455.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,910.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,854.89
|
| Rate for Payer: Ohio Health Group HMO |
$4,989.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,322.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,788.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,590.76
|
| Rate for Payer: PHCS Commercial |
$6,387.15
|
| Rate for Payer: United Healthcare All Payer |
$5,854.89
|
|
|
CIRCUM 28 DAYS OR OLDER(P
|
Professional
|
Both
|
$625.00
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
761P2132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$158.28 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$319.78
|
| Rate for Payer: Ambetter Exchange |
$187.06
|
| Rate for Payer: Anthem Medicaid |
$158.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$187.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$187.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$224.47
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$283.19
|
| Rate for Payer: Healthspan PPO |
$309.63
|
| Rate for Payer: Humana Medicaid |
$158.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$268.26
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$187.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$161.45
|
| Rate for Payer: Molina Healthcare Passport |
$158.28
|
| Rate for Payer: Multiplan PHCS |
$375.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$243.18
|
| Rate for Payer: UHCCP Medicaid |
$218.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$159.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$187.06
|
|
|
CIRCUM 28 DAYS OR OLDER(T
|
Facility
|
OP
|
$6,028.28
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
761T2132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$5,787.15 |
| Rate for Payer: Aetna Commercial |
$4,641.78
|
| Rate for Payer: Anthem Medicaid |
$2,073.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,702.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$3,014.14
|
| Rate for Payer: Cash Price |
$3,014.14
|
| Rate for Payer: Cigna Commercial |
$5,003.47
|
| Rate for Payer: First Health Commercial |
$5,726.87
|
| Rate for Payer: Humana Commercial |
$5,124.04
|
| Rate for Payer: Humana KY Medicaid |
$2,073.13
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,094.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,943.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,448.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,114.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,304.89
|
| Rate for Payer: Ohio Health Group HMO |
$4,521.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,822.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,244.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,159.51
|
| Rate for Payer: PHCS Commercial |
$5,787.15
|
| Rate for Payer: United Healthcare All Payer |
$5,304.89
|
|
|
CIRCUM 28 DAYS OR OLDER(T
|
Facility
|
IP
|
$6,028.28
|
|
|
Service Code
|
HCPCS 54161
|
| Hospital Charge Code |
761T2132
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,808.48 |
| Max. Negotiated Rate |
$5,787.15 |
| Rate for Payer: Aetna Commercial |
$4,641.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,702.06
|
| Rate for Payer: Cash Price |
$3,014.14
|
| Rate for Payer: Cigna Commercial |
$5,003.47
|
| Rate for Payer: First Health Commercial |
$5,726.87
|
| Rate for Payer: Humana Commercial |
$5,124.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,943.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,448.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,808.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,304.89
|
| Rate for Payer: Ohio Health Group HMO |
$4,521.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,822.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,244.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,159.51
|
| Rate for Payer: PHCS Commercial |
$5,787.15
|
| Rate for Payer: United Healthcare All Payer |
$5,304.89
|
|
|
CIRCUMCISION NEONATE
|
Facility
|
OP
|
$1,422.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
76102131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$489.03 |
| Max. Negotiated Rate |
$1,365.12 |
| Rate for Payer: Aetna Commercial |
$1,094.94
|
| Rate for Payer: Anthem Medicaid |
$489.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,109.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,180.26
|
| Rate for Payer: First Health Commercial |
$1,350.90
|
| Rate for Payer: Humana Commercial |
$1,208.70
|
| Rate for Payer: Humana KY Medicaid |
$489.03
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$494.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,166.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,049.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$498.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,251.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,137.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$981.18
|
| Rate for Payer: PHCS Commercial |
$1,365.12
|
| Rate for Payer: United Healthcare All Payer |
$1,251.36
|
|
|
CIRCUMCISION NEONATE
|
Facility
|
IP
|
$1,422.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
76102131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$426.60 |
| Max. Negotiated Rate |
$1,365.12 |
| Rate for Payer: Aetna Commercial |
$1,094.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,109.16
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$1,180.26
|
| Rate for Payer: First Health Commercial |
$1,350.90
|
| Rate for Payer: Humana Commercial |
$1,208.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,166.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,049.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$426.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,251.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,066.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,137.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$981.18
|
| Rate for Payer: PHCS Commercial |
$1,365.12
|
| Rate for Payer: United Healthcare All Payer |
$1,251.36
|
|
|
CIRCUMCISION NEONATE
|
Professional
|
Both
|
$1,422.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
76102131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.54 |
| Max. Negotiated Rate |
$853.20 |
| Rate for Payer: Aetna Commercial |
$236.54
|
| Rate for Payer: Ambetter Exchange |
$137.20
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.54
|
| Rate for Payer: Anthem Medicaid |
$120.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.64
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cash Price |
$711.00
|
| Rate for Payer: Cigna Commercial |
$209.22
|
| Rate for Payer: Healthspan PPO |
$357.03
|
| Rate for Payer: Humana Medicaid |
$120.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$195.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$123.35
|
| Rate for Payer: Molina Healthcare Passport |
$120.93
|
| Rate for Payer: Multiplan PHCS |
$853.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.36
|
| Rate for Payer: UHCCP Medicaid |
$77.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$122.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.20
|
|
|
CIRCUMCISION NEONATE(P
|
Professional
|
Both
|
$625.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
761P2131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.54 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$236.54
|
| Rate for Payer: Ambetter Exchange |
$137.20
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$73.54
|
| Rate for Payer: Anthem Medicaid |
$120.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$164.64
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$209.22
|
| Rate for Payer: Healthspan PPO |
$357.03
|
| Rate for Payer: Humana Medicaid |
$120.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$195.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$123.35
|
| Rate for Payer: Molina Healthcare Passport |
$120.93
|
| Rate for Payer: Multiplan PHCS |
$375.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.36
|
| Rate for Payer: UHCCP Medicaid |
$77.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$122.14
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.20
|
|
|
CIRCUMCISION NEONATE(T
|
Facility
|
OP
|
$797.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
761T2131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$274.09 |
| Max. Negotiated Rate |
$863.42 |
| Rate for Payer: Aetna Commercial |
$613.69
|
| Rate for Payer: Anthem Medicaid |
$274.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$621.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$661.51
|
| Rate for Payer: First Health Commercial |
$757.15
|
| Rate for Payer: Humana Commercial |
$677.45
|
| Rate for Payer: Humana KY Medicaid |
$274.09
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$276.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$653.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$279.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$701.36
|
| Rate for Payer: Ohio Health Group HMO |
$597.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$549.93
|
| Rate for Payer: PHCS Commercial |
$765.12
|
| Rate for Payer: United Healthcare All Payer |
$701.36
|
|
|
CIRCUMCISION NEONATE(T
|
Facility
|
IP
|
$797.00
|
|
|
Service Code
|
HCPCS 54160
|
| Hospital Charge Code |
761T2131
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$239.10 |
| Max. Negotiated Rate |
$765.12 |
| Rate for Payer: Aetna Commercial |
$613.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$621.66
|
| Rate for Payer: Cash Price |
$398.50
|
| Rate for Payer: Cigna Commercial |
$661.51
|
| Rate for Payer: First Health Commercial |
$757.15
|
| Rate for Payer: Humana Commercial |
$677.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$653.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$588.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$239.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$701.36
|
| Rate for Payer: Ohio Health Group HMO |
$597.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$637.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$693.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$549.93
|
| Rate for Payer: PHCS Commercial |
$765.12
|
| Rate for Payer: United Healthcare All Payer |
$701.36
|
|
|
CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE
|
Facility
|
OP
|
$2,649.89
|
|
|
Service Code
|
CPT 54161
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$2,649.89 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
|
|
CIRCUMCISION W/REGIONL BLOCK
|
Professional
|
Both
|
$6,935.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
76102130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.96 |
| Max. Negotiated Rate |
$4,161.00 |
| Rate for Payer: Aetna Commercial |
$161.22
|
| Rate for Payer: Ambetter Exchange |
$90.99
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$50.96
|
| Rate for Payer: Anthem Medicaid |
$76.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$90.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$90.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.19
|
| Rate for Payer: Cash Price |
$3,467.50
|
| Rate for Payer: Cash Price |
$3,467.50
|
| Rate for Payer: Cigna Commercial |
$212.89
|
| Rate for Payer: Healthspan PPO |
$258.71
|
| Rate for Payer: Humana Medicaid |
$76.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$134.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$90.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$77.80
|
| Rate for Payer: Molina Healthcare Passport |
$76.27
|
| Rate for Payer: Multiplan PHCS |
$4,161.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$118.29
|
| Rate for Payer: UHCCP Medicaid |
$53.51
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$77.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$90.99
|
|
|
CIRCUMCISION W/REGIONL BLOCK
|
Facility
|
IP
|
$6,935.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
76102130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,080.50 |
| Max. Negotiated Rate |
$6,657.60 |
| Rate for Payer: Aetna Commercial |
$5,339.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,409.30
|
| Rate for Payer: Cash Price |
$3,467.50
|
| Rate for Payer: Cigna Commercial |
$5,756.05
|
| Rate for Payer: First Health Commercial |
$6,588.25
|
| Rate for Payer: Humana Commercial |
$5,894.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,686.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,118.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,080.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,102.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,201.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,548.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,033.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,785.15
|
| Rate for Payer: PHCS Commercial |
$6,657.60
|
| Rate for Payer: United Healthcare All Payer |
$6,102.80
|
|
|
CIRCUMCISION W/REGIONL BLOCK
|
Facility
|
OP
|
$6,935.00
|
|
|
Service Code
|
HCPCS 54150
|
| Hospital Charge Code |
76102130
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,892.78 |
| Max. Negotiated Rate |
$6,657.60 |
| Rate for Payer: Aetna Commercial |
$5,339.95
|
| Rate for Payer: Anthem Medicaid |
$2,384.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,409.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$3,467.50
|
| Rate for Payer: Cash Price |
$3,467.50
|
| Rate for Payer: Cigna Commercial |
$5,756.05
|
| Rate for Payer: First Health Commercial |
$6,588.25
|
| Rate for Payer: Humana Commercial |
$5,894.75
|
| Rate for Payer: Humana KY Medicaid |
$2,384.95
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$2,409.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,686.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,118.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,432.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,102.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,201.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,548.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,033.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,785.15
|
| Rate for Payer: PHCS Commercial |
$6,657.60
|
| Rate for Payer: United Healthcare All Payer |
$6,102.80
|
|
