|
COYOTE MONORAIL 3*20
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE MONORAIL 3*220*150
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE MONORAIL 3*220*150
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE OTW 3*60*150
|
Facility
|
OP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem Medicaid |
$665.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Humana KY Medicaid |
$665.31
|
| Rate for Payer: Kentucky WC Medicaid |
$672.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$678.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COYOTE OTW 3*60*150
|
Facility
|
IP
|
$1,934.60
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$580.38 |
| Max. Negotiated Rate |
$1,857.22 |
| Rate for Payer: Aetna Commercial |
$1,489.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,508.99
|
| Rate for Payer: Cash Price |
$967.30
|
| Rate for Payer: Cigna Commercial |
$1,605.72
|
| Rate for Payer: First Health Commercial |
$1,837.87
|
| Rate for Payer: Humana Commercial |
$1,644.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,586.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,427.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$580.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,702.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,450.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,547.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,683.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,334.87
|
| Rate for Payer: PHCS Commercial |
$1,857.22
|
| Rate for Payer: United Healthcare All Payer |
$1,702.45
|
|
|
COZAAR (LOSARTAN) 50MG/1TAB
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 13668040990
|
| Hospital Charge Code |
25000493
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
COZAAR (LOSARTAN) 50MG/1TAB
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 13668040990
|
| Hospital Charge Code |
25000493
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
COZAAR (LOSARTAN POTAS) 25MG T
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 13668011390
|
| Hospital Charge Code |
25000492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
COZAAR (LOSARTAN POTAS) 25MG T
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 13668011390
|
| Hospital Charge Code |
25000492
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| 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 |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
CPAP EDUCATION
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
HCPCS 99211
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$146.40 |
| Rate for Payer: Aetna Commercial |
$13.74
|
| Rate for Payer: Ambetter Exchange |
$8.22
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$5.88
|
| Rate for Payer: Anthem Medicaid |
$16.98
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.86
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$29.84
|
| Rate for Payer: Healthspan PPO |
$21.35
|
| Rate for Payer: Humana Medicaid |
$16.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.30
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.32
|
| Rate for Payer: Molina Healthcare Passport |
$16.98
|
| Rate for Payer: Multiplan PHCS |
$146.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$10.69
|
| Rate for Payer: UHCCP Medicaid |
$6.17
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.22
|
|
|
CPAP EDUCATION
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
HCPCS 99211
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem Medicaid |
$83.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$190.32
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Humana KY Medicaid |
$83.91
|
| Rate for Payer: Kentucky WC Medicaid |
$84.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.36
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
CPAP EDUCATION
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
HCPCS 99211
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$190.32
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.36
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
CPAP EDUCATION
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$83.91 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem Medicaid |
$83.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$190.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.74
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Humana KY Medicaid |
$83.91
|
| Rate for Payer: Humana Medicare Advantage |
$119.07
|
| Rate for Payer: Kentucky WC Medicaid |
$84.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.36
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
CPAP EDUCATION
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
51000322
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$190.32
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.36
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
C-PEPTIDE SERUM
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
HCPCS 84681
|
| Hospital Charge Code |
30000559
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.70 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$119.65
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$119.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.81
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
C-PEPTIDE SERUM
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
HCPCS 84681
|
| Hospital Charge Code |
30000559
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem Medicaid |
$20.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$119.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.81
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| 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 |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$119.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.81
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
[C]PERCOCET(ACET/OXYCODON 1TAB
|
Facility
|
OP
|
$60.18
|
|
|
Service Code
|
NDC 406051201
|
| Hospital Charge Code |
25000114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| 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 |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.52
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
[C]PERCOCET(ACET/OXYCODON 1TAB
|
Facility
|
IP
|
$60.18
|
|
|
Service Code
|
NDC 406051201
|
| Hospital Charge Code |
25000114
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.05 |
| 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 |
$45.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.52
|
| Rate for Payer: PHCS Commercial |
$57.77
|
| Rate for Payer: United Healthcare All Payer |
$52.96
|
|
|
[C] PHENOBARBITAL 20 20MG/5ML
|
Facility
|
IP
|
$60.73
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.22 |
| 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 |
$48.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.90
|
| Rate for Payer: PHCS Commercial |
$58.30
|
| Rate for Payer: United Healthcare All Payer |
$53.44
|
|
|
[C] PHENOBARBITAL 20 20MG/5ML
|
Facility
|
OP
|
$60.73
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002316
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.22 |
| 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 |
$48.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.90
|
| Rate for Payer: PHCS Commercial |
$58.30
|
| Rate for Payer: United Healthcare All Payer |
$53.44
|
|
|
[C]PHENOBARBITAL SOD 65MG/1ML
|
Facility
|
IP
|
$101.18
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002317
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.35 |
| 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 |
$75.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.81
|
| Rate for Payer: PHCS Commercial |
$97.13
|
| Rate for Payer: United Healthcare All Payer |
$89.04
|
|
|
[C]PHENOBARBITAL SOD 65MG/1ML
|
Facility
|
OP
|
$101.18
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
25002317
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.35 |
| 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 |
$75.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.81
|
| Rate for Payer: PHCS Commercial |
$97.13
|
| Rate for Payer: United Healthcare All Payer |
$89.04
|
|
|
CPLX RPR FACE 2.6-7.5 CM
|
Professional
|
Both
|
$2,545.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
76100156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$152.79 |
| Max. Negotiated Rate |
$1,527.00 |
| Rate for Payer: Aetna Commercial |
$658.61
|
| Rate for Payer: Ambetter Exchange |
$282.91
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$152.79
|
| Rate for Payer: Anthem Medicaid |
$256.80
|
| Rate for Payer: Buckeye Individual/Medicaid |
$282.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$282.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$339.49
|
| Rate for Payer: Cash Price |
$1,272.50
|
| Rate for Payer: Cash Price |
$1,272.50
|
| Rate for Payer: Cigna Commercial |
$716.35
|
| Rate for Payer: Healthspan PPO |
$636.61
|
| Rate for Payer: Humana Medicaid |
$256.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$588.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$282.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$282.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$261.94
|
| Rate for Payer: Molina Healthcare Passport |
$256.80
|
| Rate for Payer: Multiplan PHCS |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$367.78
|
| Rate for Payer: UHCCP Medicaid |
$160.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$259.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$282.91
|
|
|
CPLX RPR FACE 2.6-7.5 CM
|
Facility
|
IP
|
$2,545.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
76100156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$763.50 |
| Max. Negotiated Rate |
$2,443.20 |
| Rate for Payer: Aetna Commercial |
$1,959.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,985.10
|
| Rate for Payer: Cash Price |
$1,272.50
|
| Rate for Payer: Cigna Commercial |
$2,112.35
|
| Rate for Payer: First Health Commercial |
$2,417.75
|
| Rate for Payer: Humana Commercial |
$2,163.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,086.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,878.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$763.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,239.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,908.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,036.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,214.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,756.05
|
| Rate for Payer: PHCS Commercial |
$2,443.20
|
| Rate for Payer: United Healthcare All Payer |
$2,239.60
|
|
|
CPLX RPR FACE 2.6-7.5 CM
|
Facility
|
OP
|
$2,545.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
76100156
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$565.60 |
| Max. Negotiated Rate |
$2,443.20 |
| Rate for Payer: Aetna Commercial |
$1,959.65
|
| Rate for Payer: Anthem Medicaid |
$875.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,985.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$1,272.50
|
| Rate for Payer: Cash Price |
$1,272.50
|
| Rate for Payer: Cigna Commercial |
$2,112.35
|
| Rate for Payer: First Health Commercial |
$2,417.75
|
| Rate for Payer: Humana Commercial |
$2,163.25
|
| Rate for Payer: Humana KY Medicaid |
$875.23
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$884.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,086.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,878.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$892.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,239.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,908.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,036.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,214.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,756.05
|
| Rate for Payer: PHCS Commercial |
$2,443.20
|
| Rate for Payer: United Healthcare All Payer |
$2,239.60
|
|
