|
CT UPPER EXTREMITY W/O DYE
|
Facility
|
OP
|
$2,467.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
35000052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$2,368.32 |
| Rate for Payer: Aetna Commercial |
$1,899.59
|
| Rate for Payer: Anthem Medicaid |
$848.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,924.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$1,233.50
|
| Rate for Payer: Cash Price |
$1,233.50
|
| Rate for Payer: Cigna Commercial |
$2,047.61
|
| Rate for Payer: First Health Commercial |
$2,343.65
|
| Rate for Payer: Humana Commercial |
$2,096.95
|
| Rate for Payer: Humana KY Medicaid |
$848.40
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$857.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,022.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,820.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$865.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,170.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,850.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$493.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$320.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$764.77
|
| Rate for Payer: PHCS Commercial |
$2,368.32
|
| Rate for Payer: United Healthcare All Payer |
$2,170.96
|
|
|
CT UPPER EXTREMITY W/O DYE
|
Facility
|
IP
|
$2,467.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
35000052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$320.71 |
| Max. Negotiated Rate |
$2,368.32 |
| Rate for Payer: Aetna Commercial |
$1,899.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,924.26
|
| Rate for Payer: Cash Price |
$1,233.50
|
| Rate for Payer: Cigna Commercial |
$2,047.61
|
| Rate for Payer: First Health Commercial |
$2,343.65
|
| Rate for Payer: Humana Commercial |
$2,096.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,022.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,820.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,170.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,850.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$493.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$320.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$764.77
|
| Rate for Payer: PHCS Commercial |
$2,368.32
|
| Rate for Payer: United Healthcare All Payer |
$2,170.96
|
|
|
CT UPPER EXTREMITY W/O DYE
|
Professional
|
Both
|
$2,467.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
35000052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$65.01 |
| Max. Negotiated Rate |
$2,467.00 |
| Rate for Payer: Aetna Commercial |
$380.43
|
| Rate for Payer: Anthem Medicaid |
$180.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,467.00
|
| Rate for Payer: Cash Price |
$1,233.50
|
| Rate for Payer: Cash Price |
$1,233.50
|
| Rate for Payer: Cigna Commercial |
$378.15
|
| Rate for Payer: Healthspan PPO |
$261.42
|
| Rate for Payer: Humana Medicaid |
$180.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$184.33
|
| Rate for Payer: Molina Healthcare Passport |
$180.72
|
| Rate for Payer: Multiplan PHCS |
$1,480.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,726.90
|
| Rate for Payer: UHCCP Medicaid |
$863.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$182.53
|
|
|
CT UPPER EXTREMITY W/O DYE(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
350P0052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$65.01 |
| Max. Negotiated Rate |
$380.43 |
| Rate for Payer: Aetna Commercial |
$380.43
|
| Rate for Payer: Anthem Medicaid |
$180.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$378.15
|
| Rate for Payer: Healthspan PPO |
$261.42
|
| Rate for Payer: Humana Medicaid |
$180.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$65.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$184.33
|
| Rate for Payer: Molina Healthcare Passport |
$180.72
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$182.53
|
|
|
CT UPPER EXTREMITY W/O DYE(T
|
Facility
|
IP
|
$2,242.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
350T0052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$291.46 |
| Max. Negotiated Rate |
$2,152.32 |
| Rate for Payer: Aetna Commercial |
$1,726.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,748.76
|
| Rate for Payer: Cash Price |
$1,121.00
|
| Rate for Payer: Cigna Commercial |
$1,860.86
|
| Rate for Payer: First Health Commercial |
$2,129.90
|
| Rate for Payer: Humana Commercial |
$1,905.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,838.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,654.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$672.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,972.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,681.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$695.02
|
| Rate for Payer: PHCS Commercial |
$2,152.32
|
| Rate for Payer: United Healthcare All Payer |
$1,972.96
|
|
|
CT UPPER EXTREMITY W/O DYE(T
|
Facility
|
OP
|
$2,242.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
350T0052
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$2,152.32 |
| Rate for Payer: Aetna Commercial |
$1,726.34
|
| Rate for Payer: Anthem Medicaid |
$771.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,748.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$1,121.00
|
| Rate for Payer: Cash Price |
$1,121.00
|
| Rate for Payer: Cigna Commercial |
$1,860.86
|
| Rate for Payer: First Health Commercial |
$2,129.90
|
| Rate for Payer: Humana Commercial |
$1,905.70
|
| Rate for Payer: Humana KY Medicaid |
$771.02
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$778.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,838.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,654.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$786.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,972.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,681.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$448.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$291.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$695.02
|
| Rate for Payer: PHCS Commercial |
$2,152.32
|
| Rate for Payer: United Healthcare All Payer |
$1,972.96
|
|
|
CT UPPR EXTREMITY W/O&W/DYE
|
Facility
|
OP
|
$2,778.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
35000054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$2,666.88 |
| Rate for Payer: Aetna Commercial |
$2,139.06
|
| Rate for Payer: Anthem Medicaid |
$955.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,166.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cigna Commercial |
$2,305.74
|
| Rate for Payer: First Health Commercial |
$2,639.10
|
| Rate for Payer: Humana Commercial |
$2,361.30
|
| Rate for Payer: Humana KY Medicaid |
$955.35
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$965.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,277.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,050.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$974.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,444.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,083.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$555.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$361.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$861.18
|
| Rate for Payer: PHCS Commercial |
$2,666.88
|
| Rate for Payer: United Healthcare All Payer |
$2,444.64
|
|
|
CT UPPR EXTREMITY W/O&W/DYE
|
Facility
|
IP
|
$2,778.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
35000054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$361.14 |
| Max. Negotiated Rate |
$2,666.88 |
| Rate for Payer: Aetna Commercial |
$2,139.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,166.84
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cigna Commercial |
$2,305.74
|
| Rate for Payer: First Health Commercial |
$2,639.10
|
| Rate for Payer: Humana Commercial |
$2,361.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,277.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,050.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$833.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,444.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,083.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$555.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$361.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$861.18
|
| Rate for Payer: PHCS Commercial |
$2,666.88
|
| Rate for Payer: United Healthcare All Payer |
$2,444.64
|
|
|
CT UPPR EXTREMITY W/O&W/DYE
|
Professional
|
Both
|
$2,778.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
35000054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$2,778.00 |
| Rate for Payer: Aetna Commercial |
$611.08
|
| Rate for Payer: Anthem Medicaid |
$252.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,778.00
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cash Price |
$1,389.00
|
| Rate for Payer: Cigna Commercial |
$551.98
|
| Rate for Payer: Healthspan PPO |
$419.90
|
| Rate for Payer: Humana Medicaid |
$252.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.85
|
| Rate for Payer: Molina Healthcare Passport |
$252.79
|
| Rate for Payer: Multiplan PHCS |
$1,666.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,944.60
|
| Rate for Payer: UHCCP Medicaid |
$972.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.32
|
|
|
CT UPPR EXTREMITY W/O&W/DYE(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
350P0054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$77.47 |
| Max. Negotiated Rate |
$611.08 |
| Rate for Payer: Aetna Commercial |
$611.08
|
| Rate for Payer: Anthem Medicaid |
$252.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$551.98
|
| Rate for Payer: Healthspan PPO |
$419.90
|
| Rate for Payer: Humana Medicaid |
$252.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.85
|
| Rate for Payer: Molina Healthcare Passport |
$252.79
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.32
|
|
|
CT UPPR EXTREMITY W/O&W/DYE(T
|
Facility
|
OP
|
$2,528.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
350T0054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$2,426.88 |
| Rate for Payer: Aetna Commercial |
$1,946.56
|
| Rate for Payer: Anthem Medicaid |
$869.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,971.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$1,264.00
|
| Rate for Payer: Cash Price |
$1,264.00
|
| Rate for Payer: Cigna Commercial |
$2,098.24
|
| Rate for Payer: First Health Commercial |
$2,401.60
|
| Rate for Payer: Humana Commercial |
$2,148.80
|
| Rate for Payer: Humana KY Medicaid |
$869.38
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$878.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,072.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,865.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$886.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,224.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,896.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$505.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$328.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$783.68
|
| Rate for Payer: PHCS Commercial |
$2,426.88
|
| Rate for Payer: United Healthcare All Payer |
$2,224.64
|
|
|
CT UPPR EXTREMITY W/O&W/DYE(T
|
Facility
|
IP
|
$2,528.00
|
|
|
Service Code
|
HCPCS 73202
|
| Hospital Charge Code |
350T0054
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$328.64 |
| Max. Negotiated Rate |
$2,426.88 |
| Rate for Payer: Aetna Commercial |
$1,946.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,971.84
|
| Rate for Payer: Cash Price |
$1,264.00
|
| Rate for Payer: Cigna Commercial |
$2,098.24
|
| Rate for Payer: First Health Commercial |
$2,401.60
|
| Rate for Payer: Humana Commercial |
$2,148.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,072.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,865.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$758.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,224.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,896.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$505.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$328.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$783.68
|
| Rate for Payer: PHCS Commercial |
$2,426.88
|
| Rate for Payer: United Healthcare All Payer |
$2,224.64
|
|
|
[C]TUSSIONEX (COMB) SUSPEN 5ML
|
Facility
|
OP
|
$62.41
|
|
|
Service Code
|
NDC 27808008602
|
| Hospital Charge Code |
25000124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$59.91 |
| Rate for Payer: Aetna Commercial |
$48.06
|
| Rate for Payer: Anthem Medicaid |
$21.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.68
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$51.80
|
| Rate for Payer: First Health Commercial |
$59.29
|
| Rate for Payer: Humana Commercial |
$53.05
|
| Rate for Payer: Humana KY Medicaid |
$21.46
|
| Rate for Payer: Kentucky WC Medicaid |
$21.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.92
|
| Rate for Payer: Ohio Health Group HMO |
$46.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.35
|
| Rate for Payer: PHCS Commercial |
$59.91
|
| Rate for Payer: United Healthcare All Payer |
$54.92
|
|
|
[C]TUSSIONEX (COMB) SUSPEN 5ML
|
Facility
|
IP
|
$62.41
|
|
|
Service Code
|
NDC 27808008602
|
| Hospital Charge Code |
25000124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.11 |
| Max. Negotiated Rate |
$59.91 |
| Rate for Payer: Aetna Commercial |
$48.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.68
|
| Rate for Payer: Cash Price |
$31.20
|
| Rate for Payer: Cigna Commercial |
$51.80
|
| Rate for Payer: First Health Commercial |
$59.29
|
| Rate for Payer: Humana Commercial |
$53.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$54.92
|
| Rate for Payer: Ohio Health Group HMO |
$46.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.35
|
| Rate for Payer: PHCS Commercial |
$59.91
|
| Rate for Payer: United Healthcare All Payer |
$54.92
|
|
|
[C]TYLENOL #2 (ACETAMIN. 1TAB
|
Facility
|
OP
|
$60.42
|
|
|
Service Code
|
NDC 406048301
|
| Hospital Charge Code |
25000083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$46.52
|
| Rate for Payer: Anthem Medicaid |
$20.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.13
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna Commercial |
$50.15
|
| Rate for Payer: First Health Commercial |
$57.40
|
| Rate for Payer: Humana Commercial |
$51.36
|
| Rate for Payer: Humana KY Medicaid |
$20.78
|
| Rate for Payer: Kentucky WC Medicaid |
$20.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.17
|
| Rate for Payer: Ohio Health Group HMO |
$45.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.73
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
[C]TYLENOL #2 (ACETAMIN. 1TAB
|
Facility
|
IP
|
$60.42
|
|
|
Service Code
|
NDC 406048301
|
| Hospital Charge Code |
25000083
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$58.00 |
| Rate for Payer: Aetna Commercial |
$46.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.13
|
| Rate for Payer: Cash Price |
$30.21
|
| Rate for Payer: Cigna Commercial |
$50.15
|
| Rate for Payer: First Health Commercial |
$57.40
|
| Rate for Payer: Humana Commercial |
$51.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.17
|
| Rate for Payer: Ohio Health Group HMO |
$45.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.73
|
| Rate for Payer: PHCS Commercial |
$58.00
|
| Rate for Payer: United Healthcare All Payer |
$53.17
|
|
|
[C]TYLENOL #4 (ACETAMIN. 1TAB
|
Facility
|
OP
|
$60.58
|
|
|
Service Code
|
NDC 406048501
|
| Hospital Charge Code |
25000085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$58.16 |
| Rate for Payer: Aetna Commercial |
$46.65
|
| Rate for Payer: Anthem Medicaid |
$20.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.25
|
| Rate for Payer: Cash Price |
$30.29
|
| Rate for Payer: Cigna Commercial |
$50.28
|
| Rate for Payer: First Health Commercial |
$57.55
|
| Rate for Payer: Humana Commercial |
$51.49
|
| Rate for Payer: Humana KY Medicaid |
$20.83
|
| Rate for Payer: Kentucky WC Medicaid |
$21.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.31
|
| Rate for Payer: Ohio Health Group HMO |
$45.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.78
|
| Rate for Payer: PHCS Commercial |
$58.16
|
| Rate for Payer: United Healthcare All Payer |
$53.31
|
|
|
[C]TYLENOL #4 (ACETAMIN. 1TAB
|
Facility
|
IP
|
$60.58
|
|
|
Service Code
|
NDC 406048501
|
| Hospital Charge Code |
25000085
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.88 |
| Max. Negotiated Rate |
$58.16 |
| Rate for Payer: Aetna Commercial |
$46.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.25
|
| Rate for Payer: Cash Price |
$30.29
|
| Rate for Payer: Cigna Commercial |
$50.28
|
| Rate for Payer: First Health Commercial |
$57.55
|
| Rate for Payer: Humana Commercial |
$51.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.31
|
| Rate for Payer: Ohio Health Group HMO |
$45.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.78
|
| Rate for Payer: PHCS Commercial |
$58.16
|
| Rate for Payer: United Healthcare All Payer |
$53.31
|
|
|
[C]TYLNOL #3 (ACETAMIN. 1 TAB
|
Facility
|
IP
|
$60.40
|
|
|
Service Code
|
NDC 406048462
|
| Hospital Charge Code |
25000084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$57.98 |
| Rate for Payer: Aetna Commercial |
$46.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.11
|
| Rate for Payer: Cash Price |
$30.20
|
| Rate for Payer: Cigna Commercial |
$50.13
|
| Rate for Payer: First Health Commercial |
$57.38
|
| Rate for Payer: Humana Commercial |
$51.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.15
|
| Rate for Payer: Ohio Health Group HMO |
$45.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.72
|
| Rate for Payer: PHCS Commercial |
$57.98
|
| Rate for Payer: United Healthcare All Payer |
$53.15
|
|
|
[C]TYLNOL #3 (ACETAMIN. 1 TAB
|
Facility
|
OP
|
$60.40
|
|
|
Service Code
|
NDC 406048462
|
| Hospital Charge Code |
25000084
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.85 |
| Max. Negotiated Rate |
$57.98 |
| Rate for Payer: Aetna Commercial |
$46.51
|
| Rate for Payer: Anthem Medicaid |
$20.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.11
|
| Rate for Payer: Cash Price |
$30.20
|
| Rate for Payer: Cigna Commercial |
$50.13
|
| Rate for Payer: First Health Commercial |
$57.38
|
| Rate for Payer: Humana Commercial |
$51.34
|
| Rate for Payer: Humana KY Medicaid |
$20.77
|
| Rate for Payer: Kentucky WC Medicaid |
$20.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.15
|
| Rate for Payer: Ohio Health Group HMO |
$45.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.72
|
| Rate for Payer: PHCS Commercial |
$57.98
|
| Rate for Payer: United Healthcare All Payer |
$53.15
|
|
|
CUBICIN (GEN) 1MG (350MG)SDV
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
25004086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.80 |
| Rate for Payer: Aetna Commercial |
$157.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.90
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$170.15
|
| Rate for Payer: First Health Commercial |
$194.75
|
| Rate for Payer: Humana Commercial |
$174.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.40
|
| Rate for Payer: Ohio Health Group HMO |
$153.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.55
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
CUBICIN (GEN) 1MG (350MG)SDV
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
25004086
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.65 |
| Max. Negotiated Rate |
$196.80 |
| Rate for Payer: Aetna Commercial |
$157.85
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.90
|
| Rate for Payer: Cash Price |
$102.50
|
| Rate for Payer: Cigna Commercial |
$170.15
|
| Rate for Payer: First Health Commercial |
$194.75
|
| Rate for Payer: Humana Commercial |
$174.25
|
| Rate for Payer: Humana KY Medicaid |
$70.50
|
| Rate for Payer: Kentucky WC Medicaid |
$71.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.40
|
| Rate for Payer: Ohio Health Group HMO |
$153.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.55
|
| Rate for Payer: PHCS Commercial |
$196.80
|
| Rate for Payer: United Healthcare All Payer |
$180.40
|
|
|
CUBICIN (GEN) 1MG (500MG)SDV
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
25001973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem Medicaid |
$63.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Humana KY Medicaid |
$63.97
|
| Rate for Payer: Kentucky WC Medicaid |
$64.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
CUBICIN (GEN) 1MG (500MG)SDV
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
25001973
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
CUBICIN (GENERIC) 1MG (500MG)
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS J0878
|
| Hospital Charge Code |
25001975
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
