|
CUTTING BALLOON 6*2*135
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
| Rate for Payer: Aetna Commercial |
$3,580.50
|
|
|
CUTTING BALLOON 6*2*135
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 6*2*50
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 6*2*50
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 6*2*90
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 6*2*90
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 7*2*50
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 7*2*50
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 8*2*50
|
Facility
|
IP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
CUTTING BALLOON 8*2*50
|
Facility
|
OP
|
$4,650.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$604.50 |
| Max. Negotiated Rate |
$4,464.00 |
| Rate for Payer: Aetna Commercial |
$3,580.50
|
| Rate for Payer: Anthem Medicaid |
$1,599.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,627.00
|
| Rate for Payer: Cash Price |
$2,325.00
|
| Rate for Payer: Cigna Commercial |
$3,859.50
|
| Rate for Payer: First Health Commercial |
$4,417.50
|
| Rate for Payer: Humana Commercial |
$3,952.50
|
| Rate for Payer: Humana KY Medicaid |
$1,599.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,615.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,813.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,431.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,395.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,631.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,092.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$930.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$604.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,441.50
|
| Rate for Payer: PHCS Commercial |
$4,464.00
|
| Rate for Payer: United Healthcare All Payer |
$4,092.00
|
|
|
[C]VALIUM (DIAZEPAM) 2MG/1TAB
|
Facility
|
IP
|
$60.06
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
25000086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.66 |
| Rate for Payer: Aetna Commercial |
$46.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.85
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cigna Commercial |
$49.85
|
| Rate for Payer: First Health Commercial |
$57.06
|
| Rate for Payer: Humana Commercial |
$51.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.85
|
| Rate for Payer: Ohio Health Group HMO |
$45.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.62
|
| Rate for Payer: PHCS Commercial |
$57.66
|
| Rate for Payer: United Healthcare All Payer |
$52.85
|
|
|
[C]VALIUM (DIAZEPAM) 2MG/1TAB
|
Facility
|
OP
|
$60.06
|
|
|
Service Code
|
NDC 51079028420
|
| Hospital Charge Code |
25000086
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.66 |
| Rate for Payer: Anthem Medicaid |
$20.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.85
|
| Rate for Payer: Cash Price |
$30.03
|
| Rate for Payer: Cigna Commercial |
$49.85
|
| Rate for Payer: First Health Commercial |
$57.06
|
| Rate for Payer: Humana Commercial |
$51.05
|
| Rate for Payer: Humana KY Medicaid |
$20.65
|
| Rate for Payer: Kentucky WC Medicaid |
$20.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.25
|
| Rate for Payer: Aetna Commercial |
$46.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.85
|
| Rate for Payer: Ohio Health Group HMO |
$45.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.62
|
| Rate for Payer: PHCS Commercial |
$57.66
|
| Rate for Payer: United Healthcare All Payer |
$52.85
|
|
|
[C]VERSED (MIDAZOLAM) 10MG/2ML
|
Facility
|
OP
|
$76.23
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$73.18 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.46
|
| Rate for Payer: Cash Price |
$38.12
|
| Rate for Payer: Cigna Commercial |
$63.27
|
| Rate for Payer: First Health Commercial |
$72.42
|
| Rate for Payer: Humana Commercial |
$64.80
|
| Rate for Payer: Humana KY Medicaid |
$26.22
|
| Rate for Payer: Kentucky WC Medicaid |
$26.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.08
|
| Rate for Payer: Ohio Health Group HMO |
$57.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.63
|
| Rate for Payer: PHCS Commercial |
$73.18
|
| Rate for Payer: United Healthcare All Payer |
$67.08
|
| Rate for Payer: Aetna Commercial |
$58.70
|
| Rate for Payer: Anthem Medicaid |
$26.22
|
|
|
[C]VERSED (MIDAZOLAM) 10MG/2ML
|
Facility
|
IP
|
$76.23
|
|
|
Service Code
|
HCPCS J2250
|
| Hospital Charge Code |
25002233
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$73.18 |
| Rate for Payer: Aetna Commercial |
$58.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.46
|
| Rate for Payer: Cash Price |
$38.12
|
| Rate for Payer: Cigna Commercial |
$63.27
|
| Rate for Payer: First Health Commercial |
$72.42
|
| Rate for Payer: Humana Commercial |
$64.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.08
|
| Rate for Payer: Ohio Health Group HMO |
$57.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.63
|
| Rate for Payer: PHCS Commercial |
$73.18
|
| Rate for Payer: United Healthcare All Payer |
$67.08
|
|
|
[C]XANAX (ALPRAZOLA .5MG/1TAB
|
Facility
|
OP
|
$60.05
|
|
|
Service Code
|
NDC 228202910
|
| Hospital Charge Code |
25000088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.65 |
| Rate for Payer: Aetna Commercial |
$46.24
|
| Rate for Payer: Anthem Medicaid |
$20.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.84
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cigna Commercial |
$49.84
|
| Rate for Payer: First Health Commercial |
$57.05
|
| Rate for Payer: Humana Commercial |
$51.04
|
| Rate for Payer: Humana KY Medicaid |
$20.65
|
| Rate for Payer: Kentucky WC Medicaid |
$20.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.84
|
| Rate for Payer: Ohio Health Group HMO |
$45.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.62
|
| Rate for Payer: PHCS Commercial |
$57.65
|
| Rate for Payer: United Healthcare All Payer |
$52.84
|
|
|
[C]XANAX (ALPRAZOLA .5MG/1TAB
|
Facility
|
IP
|
$60.05
|
|
|
Service Code
|
NDC 228202910
|
| Hospital Charge Code |
25000088
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.65 |
| Rate for Payer: Aetna Commercial |
$46.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.84
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cigna Commercial |
$49.84
|
| Rate for Payer: First Health Commercial |
$57.05
|
| Rate for Payer: Humana Commercial |
$51.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.84
|
| Rate for Payer: Ohio Health Group HMO |
$45.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.62
|
| Rate for Payer: PHCS Commercial |
$57.65
|
| Rate for Payer: United Healthcare All Payer |
$52.84
|
|
|
[C]XANAX (ALPRZOL 0.25MG/1TAB
|
Facility
|
OP
|
$60.04
|
|
|
Service Code
|
NDC 65862067601
|
| Hospital Charge Code |
25000087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.64 |
| Rate for Payer: Aetna Commercial |
$46.23
|
| Rate for Payer: Anthem Medicaid |
$20.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.83
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cigna Commercial |
$49.83
|
| Rate for Payer: First Health Commercial |
$57.04
|
| Rate for Payer: Humana Commercial |
$51.03
|
| Rate for Payer: Humana KY Medicaid |
$20.65
|
| Rate for Payer: Kentucky WC Medicaid |
$20.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.84
|
| Rate for Payer: Ohio Health Group HMO |
$45.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.61
|
| Rate for Payer: PHCS Commercial |
$57.64
|
| Rate for Payer: United Healthcare All Payer |
$52.84
|
|
|
[C]XANAX (ALPRZOL 0.25MG/1TAB
|
Facility
|
IP
|
$60.04
|
|
|
Service Code
|
NDC 65862067601
|
| Hospital Charge Code |
25000087
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$57.64 |
| Rate for Payer: Aetna Commercial |
$46.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.83
|
| Rate for Payer: Cash Price |
$30.02
|
| Rate for Payer: Cigna Commercial |
$49.83
|
| Rate for Payer: First Health Commercial |
$57.04
|
| Rate for Payer: Humana Commercial |
$51.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.84
|
| Rate for Payer: Ohio Health Group HMO |
$45.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.61
|
| Rate for Payer: PHCS Commercial |
$57.64
|
| Rate for Payer: United Healthcare All Payer |
$52.84
|
|
|
CXI SUPPORT CATH. .014 ANG 150
|
Facility
|
IP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .014 ANG 150
|
Facility
|
OP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem Medicaid |
$698.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Humana KY Medicaid |
$698.98
|
| Rate for Payer: Kentucky WC Medicaid |
$706.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$713.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .014 STR 150
|
Facility
|
OP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem Medicaid |
$698.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Humana KY Medicaid |
$698.98
|
| Rate for Payer: Kentucky WC Medicaid |
$706.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$713.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .014 STR 150
|
Facility
|
IP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .018 ANG 150
|
Facility
|
IP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .018 ANG 150
|
Facility
|
OP
|
$2,032.50
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$264.22 |
| Max. Negotiated Rate |
$1,951.20 |
| Rate for Payer: Aetna Commercial |
$1,565.02
|
| Rate for Payer: Anthem Medicaid |
$698.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,585.35
|
| Rate for Payer: Cash Price |
$1,016.25
|
| Rate for Payer: Cigna Commercial |
$1,686.98
|
| Rate for Payer: First Health Commercial |
$1,930.88
|
| Rate for Payer: Humana Commercial |
$1,727.62
|
| Rate for Payer: Humana KY Medicaid |
$698.98
|
| Rate for Payer: Kentucky WC Medicaid |
$706.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,666.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,499.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$609.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$713.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,788.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,524.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$406.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$264.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.08
|
| Rate for Payer: PHCS Commercial |
$1,951.20
|
| Rate for Payer: United Healthcare All Payer |
$1,788.60
|
|
|
CXI SUPPORT CATH. .018 STR 150
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| 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 |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
