|
COZAAR (LOSARTAN POTAS) 25MG T
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 13668011390
|
| Hospital Charge Code |
25000492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
| Rate for Payer: Aetna Commercial |
$3.34
|
|
|
COZAAR (LOSARTAN POTAS) 25MG T
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 13668011390
|
| Hospital Charge Code |
25000492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
CPAP EDUCATION
|
Facility
|
OP
|
$238.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$228.48 |
| Rate for Payer: Aetna Commercial |
$183.26
|
| Rate for Payer: Anthem Medicaid |
$81.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$185.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$197.54
|
| Rate for Payer: First Health Commercial |
$226.10
|
| Rate for Payer: Humana Commercial |
$202.30
|
| Rate for Payer: Humana KY Medicaid |
$81.85
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$82.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$195.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$175.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$83.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$209.44
|
| Rate for Payer: Ohio Health Group HMO |
$178.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.78
|
| Rate for Payer: PHCS Commercial |
$228.48
|
| Rate for Payer: United Healthcare All Payer |
$209.44
|
|
|
CPAP EDUCATION
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
HCPCS 99211
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.88
|
| Rate for Payer: Anthem Medicaid |
$7.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$238.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$29.84
|
| Rate for Payer: Healthspan PPO |
$21.35
|
| Rate for Payer: Humana Medicaid |
$7.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$7.63
|
| Rate for Payer: Molina Healthcare Passport |
$7.48
|
| Rate for Payer: Multiplan PHCS |
$142.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$166.60
|
| Rate for Payer: UHCCP Medicaid |
$6.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$7.55
|
|
|
CPAP EDUCATION
|
Facility
|
IP
|
$238.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$228.48 |
| Rate for Payer: Aetna Commercial |
$183.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$185.64
|
| Rate for Payer: Cash Price |
$119.00
|
| Rate for Payer: Cigna Commercial |
$197.54
|
| Rate for Payer: First Health Commercial |
$226.10
|
| Rate for Payer: Humana Commercial |
$202.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$195.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$175.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$71.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$209.44
|
| Rate for Payer: Ohio Health Group HMO |
$178.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.78
|
| Rate for Payer: PHCS Commercial |
$228.48
|
| Rate for Payer: United Healthcare All Payer |
$209.44
|
|
|
C-PEPTIDE SERUM
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
HCPCS 84681
|
| Hospital Charge Code |
30000559
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.42
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
C-PEPTIDE SERUM
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
HCPCS 84681
|
| Hospital Charge Code |
30000559
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.20 |
| Max. Negotiated Rate |
$134.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Anthem Medicaid |
$20.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.81
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cash Price |
$70.00
|
| Rate for Payer: Cigna Commercial |
$116.20
|
| Rate for Payer: First Health Commercial |
$133.00
|
| Rate for Payer: Humana Commercial |
$119.00
|
| Rate for Payer: Humana KY Medicaid |
$20.81
|
| Rate for Payer: Humana Medicare Advantage |
$20.81
|
| Rate for Payer: Kentucky WC Medicaid |
$21.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$114.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$103.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$123.20
|
| Rate for Payer: Ohio Health Group HMO |
$105.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.40
|
| Rate for Payer: PHCS Commercial |
$134.40
|
| Rate for Payer: United Healthcare All Payer |
$123.20
|
|
|
[C]PERCOCET(ACET/OXYCODON 1TAB
|
Facility
|
IP
|
$60.18
|
|
|
Service Code
|
NDC 406051201
|
| Hospital Charge Code |
25000114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.77 |
| Rate for Payer: Aetna Commercial |
$46.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.94
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.95
|
| Rate for Payer: First Health Commercial |
$57.17
|
| Rate for Payer: Humana Commercial |
$51.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.96
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.66
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
[C]PERCOCET(ACET/OXYCODON 1TAB
|
Facility
|
OP
|
$60.18
|
|
|
Service Code
|
NDC 406051201
|
| Hospital Charge Code |
25000114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.82 |
| Max. Negotiated Rate |
$57.77 |
| Rate for Payer: Aetna Commercial |
$46.34
|
| Rate for Payer: Anthem Medicaid |
$20.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.94
|
| Rate for Payer: Cash Price |
$30.09
|
| Rate for Payer: Cigna Commercial |
$49.95
|
| Rate for Payer: First Health Commercial |
$57.17
|
| Rate for Payer: Humana Commercial |
$51.15
|
| Rate for Payer: Humana KY Medicaid |
$20.70
|
| Rate for Payer: Kentucky WC Medicaid |
$20.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.96
|
| Rate for Payer: Ohio Health Group HMO |
$45.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.66
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
[C]PHENERGAN VC /COD.SYRU 10ML
|
Facility
|
IP
|
$62.54
|
|
|
Service Code
|
NDC 121092516
|
| Hospital Charge Code |
25000115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$60.04 |
| Rate for Payer: Aetna Commercial |
$48.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Cigna Commercial |
$51.91
|
| Rate for Payer: First Health Commercial |
$59.41
|
| Rate for Payer: Humana Commercial |
$53.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.04
|
| Rate for Payer: Ohio Health Group HMO |
$46.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.39
|
| Rate for Payer: PHCS Commercial |
$60.04
|
| Rate for Payer: United Healthcare All Payer |
$55.04
|
|
|
[C]PHENERGAN VC /COD.SYRU 10ML
|
Facility
|
OP
|
$62.54
|
|
|
Service Code
|
NDC 121092516
|
| Hospital Charge Code |
25000115
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$60.04 |
| Rate for Payer: Anthem Medicaid |
$21.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.78
|
| Rate for Payer: Cash Price |
$31.27
|
| Rate for Payer: Cigna Commercial |
$51.91
|
| Rate for Payer: First Health Commercial |
$59.41
|
| Rate for Payer: Humana Commercial |
$53.16
|
| Rate for Payer: Humana KY Medicaid |
$21.51
|
| Rate for Payer: Kentucky WC Medicaid |
$21.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.28
|
| Rate for Payer: Aetna Commercial |
$48.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.04
|
| Rate for Payer: Ohio Health Group HMO |
$46.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.39
|
| Rate for Payer: PHCS Commercial |
$60.04
|
| Rate for Payer: United Healthcare All Payer |
$55.04
|
|
|
[C] PHENOBARBITAL 20 20MG/5ML
|
Facility
|
OP
|
$60.73
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.89 |
| Max. Negotiated Rate |
$58.30 |
| Rate for Payer: Aetna Commercial |
$46.76
|
| Rate for Payer: Anthem Medicaid |
$20.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.37
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Cigna Commercial |
$50.41
|
| Rate for Payer: First Health Commercial |
$57.69
|
| Rate for Payer: Humana Commercial |
$51.62
|
| Rate for Payer: Humana KY Medicaid |
$20.89
|
| Rate for Payer: Kentucky WC Medicaid |
$21.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.44
|
| Rate for Payer: Ohio Health Group HMO |
$45.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.83
|
| Rate for Payer: PHCS Commercial |
$58.30
|
| Rate for Payer: United Healthcare All Payer |
$53.44
|
|
|
[C] PHENOBARBITAL 20 20MG/5ML
|
Facility
|
IP
|
$60.73
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.89 |
| Max. Negotiated Rate |
$58.30 |
| Rate for Payer: Aetna Commercial |
$46.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.37
|
| Rate for Payer: Cash Price |
$30.36
|
| Rate for Payer: Cigna Commercial |
$50.41
|
| Rate for Payer: First Health Commercial |
$57.69
|
| Rate for Payer: Humana Commercial |
$51.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.44
|
| Rate for Payer: Ohio Health Group HMO |
$45.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.83
|
| Rate for Payer: PHCS Commercial |
$58.30
|
| Rate for Payer: United Healthcare All Payer |
$53.44
|
|
|
[C]PHENOBARBITAL SOD 65MG/1ML
|
Facility
|
OP
|
$101.18
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002317
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.15 |
| Max. Negotiated Rate |
$97.13 |
| Rate for Payer: Aetna Commercial |
$77.91
|
| Rate for Payer: Anthem Medicaid |
$34.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.92
|
| Rate for Payer: Cash Price |
$50.59
|
| Rate for Payer: Cigna Commercial |
$83.98
|
| Rate for Payer: First Health Commercial |
$96.12
|
| Rate for Payer: Humana Commercial |
$86.00
|
| Rate for Payer: Humana KY Medicaid |
$34.80
|
| Rate for Payer: Kentucky WC Medicaid |
$35.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.04
|
| Rate for Payer: Ohio Health Group HMO |
$75.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.37
|
| Rate for Payer: PHCS Commercial |
$97.13
|
| Rate for Payer: United Healthcare All Payer |
$89.04
|
|
|
[C]PHENOBARBITAL SOD 65MG/1ML
|
Facility
|
IP
|
$101.18
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002317
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.15 |
| Max. Negotiated Rate |
$97.13 |
| Rate for Payer: Aetna Commercial |
$77.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.92
|
| Rate for Payer: Cash Price |
$50.59
|
| Rate for Payer: Cigna Commercial |
$83.98
|
| Rate for Payer: First Health Commercial |
$96.12
|
| Rate for Payer: Humana Commercial |
$86.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$74.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$89.04
|
| Rate for Payer: Ohio Health Group HMO |
$75.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.37
|
| Rate for Payer: PHCS Commercial |
$97.13
|
| Rate for Payer: United Healthcare All Payer |
$89.04
|
|
|
CPLX RPR FACE 2.6-7.5 CM
|
Facility
|
IP
|
$2,435.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
76100156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$316.55 |
| Max. Negotiated Rate |
$2,337.60 |
| Rate for Payer: Aetna Commercial |
$1,874.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,899.30
|
| Rate for Payer: Cash Price |
$1,217.50
|
| Rate for Payer: Cigna Commercial |
$2,021.05
|
| Rate for Payer: First Health Commercial |
$2,313.25
|
| Rate for Payer: Humana Commercial |
$2,069.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,996.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,797.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$730.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,142.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,826.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$487.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$754.85
|
| Rate for Payer: PHCS Commercial |
$2,337.60
|
| Rate for Payer: United Healthcare All Payer |
$2,142.80
|
|
|
CPLX RPR FACE 2.6-7.5 CM
|
Facility
|
OP
|
$2,435.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
76100156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$316.55 |
| Max. Negotiated Rate |
$2,337.60 |
| Rate for Payer: Aetna Commercial |
$1,874.95
|
| Rate for Payer: Anthem Medicaid |
$837.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,899.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$1,217.50
|
| Rate for Payer: Cash Price |
$1,217.50
|
| Rate for Payer: Cigna Commercial |
$2,021.05
|
| Rate for Payer: First Health Commercial |
$2,313.25
|
| Rate for Payer: Humana Commercial |
$2,069.75
|
| Rate for Payer: Humana KY Medicaid |
$837.40
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$845.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,996.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,797.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$854.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,142.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,826.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$487.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$316.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$754.85
|
| Rate for Payer: PHCS Commercial |
$2,337.60
|
| Rate for Payer: United Healthcare All Payer |
$2,142.80
|
|
|
CPLX RPR FACE 2.6-7.5 CM
|
Professional
|
Both
|
$2,435.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
76100156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.79 |
| Max. Negotiated Rate |
$2,435.00 |
| Rate for Payer: Aetna Commercial |
$658.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$152.79
|
| Rate for Payer: Anthem Medicaid |
$195.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,435.00
|
| Rate for Payer: Cash Price |
$1,217.50
|
| Rate for Payer: Cash Price |
$1,217.50
|
| Rate for Payer: Cigna Commercial |
$716.35
|
| Rate for Payer: Healthspan PPO |
$636.61
|
| Rate for Payer: Humana Medicaid |
$195.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$588.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$199.43
|
| Rate for Payer: Molina Healthcare Passport |
$195.52
|
| Rate for Payer: Multiplan PHCS |
$1,461.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,704.50
|
| Rate for Payer: UHCCP Medicaid |
$160.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$197.48
|
|
|
CPLX RPR FACE 2.6-7.5 CM(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
761P0156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.79 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$658.61
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$152.79
|
| Rate for Payer: Anthem Medicaid |
$195.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$716.35
|
| Rate for Payer: Healthspan PPO |
$636.61
|
| Rate for Payer: Humana Medicaid |
$195.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$588.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$199.43
|
| Rate for Payer: Molina Healthcare Passport |
$195.52
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$160.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$197.48
|
|
|
CPLX RPR FACE 2.6-7.5 CM(T
|
Facility
|
IP
|
$1,685.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
761T0156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.05 |
| Max. Negotiated Rate |
$1,617.60 |
| Rate for Payer: Aetna Commercial |
$1,297.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,314.30
|
| Rate for Payer: Cash Price |
$842.50
|
| Rate for Payer: Cigna Commercial |
$1,398.55
|
| Rate for Payer: First Health Commercial |
$1,600.75
|
| Rate for Payer: Humana Commercial |
$1,432.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,243.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$505.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$337.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$522.35
|
| Rate for Payer: PHCS Commercial |
$1,617.60
|
| Rate for Payer: United Healthcare All Payer |
$1,482.80
|
|
|
CPLX RPR FACE 2.6-7.5 CM(T
|
Facility
|
OP
|
$1,685.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
761T0156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$219.05 |
| Max. Negotiated Rate |
$1,617.60 |
| Rate for Payer: Aetna Commercial |
$1,297.45
|
| Rate for Payer: Anthem Medicaid |
$579.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,314.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$842.50
|
| Rate for Payer: Cash Price |
$842.50
|
| Rate for Payer: Cigna Commercial |
$1,398.55
|
| Rate for Payer: First Health Commercial |
$1,600.75
|
| Rate for Payer: Humana Commercial |
$1,432.25
|
| Rate for Payer: Humana KY Medicaid |
$579.47
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$585.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,243.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$591.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$337.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$522.35
|
| Rate for Payer: PHCS Commercial |
$1,617.60
|
| Rate for Payer: United Healthcare All Payer |
$1,482.80
|
|
|
CPLX RPR SC - EXT 1.1-2.5
|
Facility
|
IP
|
$1,780.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
76100152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$231.40 |
| Max. Negotiated Rate |
$1,708.80 |
| Rate for Payer: Aetna Commercial |
$1,370.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,388.40
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,477.40
|
| Rate for Payer: First Health Commercial |
$1,691.00
|
| Rate for Payer: Humana Commercial |
$1,513.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,459.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,313.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$534.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,566.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,335.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.80
|
| Rate for Payer: PHCS Commercial |
$1,708.80
|
| Rate for Payer: United Healthcare All Payer |
$1,566.40
|
|
|
CPLX RPR SC - EXT 1.1-2.5
|
Professional
|
Both
|
$1,780.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
76100152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$1,780.00 |
| Rate for Payer: Aetna Commercial |
$349.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$118.01
|
| Rate for Payer: Anthem Medicaid |
$117.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,780.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$426.18
|
| Rate for Payer: Healthspan PPO |
$361.48
|
| Rate for Payer: Humana Medicaid |
$117.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$306.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$119.95
|
| Rate for Payer: Molina Healthcare Passport |
$117.60
|
| Rate for Payer: Multiplan PHCS |
$1,068.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,246.00
|
| Rate for Payer: UHCCP Medicaid |
$123.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$118.78
|
|
|
CPLX RPR SC - EXT 1.1-2.5
|
Facility
|
OP
|
$1,780.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
76100152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$231.40 |
| Max. Negotiated Rate |
$1,708.80 |
| Rate for Payer: Aetna Commercial |
$1,370.60
|
| Rate for Payer: Anthem Medicaid |
$612.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,388.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,477.40
|
| Rate for Payer: First Health Commercial |
$1,691.00
|
| Rate for Payer: Humana Commercial |
$1,513.00
|
| Rate for Payer: Humana KY Medicaid |
$612.14
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$618.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,459.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,313.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$624.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,566.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,335.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.80
|
| Rate for Payer: PHCS Commercial |
$1,708.80
|
| Rate for Payer: United Healthcare All Payer |
$1,566.40
|
|
|
CPLX RPR SC - EXT 1.1-2.5(P
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
761P0152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.60 |
| Max. Negotiated Rate |
$426.18 |
| Rate for Payer: Aetna Commercial |
$349.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$118.01
|
| Rate for Payer: Anthem Medicaid |
$117.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$425.00
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$426.18
|
| Rate for Payer: Healthspan PPO |
$361.48
|
| Rate for Payer: Humana Medicaid |
$117.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$306.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$119.95
|
| Rate for Payer: Molina Healthcare Passport |
$117.60
|
| Rate for Payer: Multiplan PHCS |
$255.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$297.50
|
| Rate for Payer: UHCCP Medicaid |
$123.91
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$118.78
|
|
