|
DUCK FEATHERS IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000712
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
DUCTOGRAM MULTI DUCT S&I
|
Professional
|
Both
|
$698.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
40200086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$29.03 |
| Max. Negotiated Rate |
$698.00 |
| Rate for Payer: Aetna Commercial |
$159.20
|
| Rate for Payer: Anthem Medicaid |
$100.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$698.00
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cigna Commercial |
$214.74
|
| Rate for Payer: Healthspan PPO |
$149.18
|
| Rate for Payer: Humana Medicaid |
$100.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.76
|
| Rate for Payer: Molina Healthcare Passport |
$100.75
|
| Rate for Payer: Multiplan PHCS |
$418.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$488.60
|
| Rate for Payer: UHCCP Medicaid |
$244.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.76
|
|
|
DUCTOGRAM MULTI DUCT S&I
|
Facility
|
OP
|
$698.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
40200086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$90.74 |
| Max. Negotiated Rate |
$670.08 |
| Rate for Payer: Aetna Commercial |
$537.46
|
| Rate for Payer: Anthem Medicaid |
$240.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$544.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cigna Commercial |
$579.34
|
| Rate for Payer: First Health Commercial |
$663.10
|
| Rate for Payer: Humana Commercial |
$593.30
|
| Rate for Payer: Humana KY Medicaid |
$240.04
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$242.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$572.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$515.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$244.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$614.24
|
| Rate for Payer: Ohio Health Group HMO |
$523.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$139.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$216.38
|
| Rate for Payer: PHCS Commercial |
$670.08
|
| Rate for Payer: United Healthcare All Payer |
$614.24
|
|
|
DUCTOGRAM MULTI DUCT S&I
|
Facility
|
IP
|
$698.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
40200086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$90.74 |
| Max. Negotiated Rate |
$670.08 |
| Rate for Payer: Aetna Commercial |
$537.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$544.44
|
| Rate for Payer: Cash Price |
$349.00
|
| Rate for Payer: Cigna Commercial |
$579.34
|
| Rate for Payer: First Health Commercial |
$663.10
|
| Rate for Payer: Humana Commercial |
$593.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$572.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$515.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$209.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$614.24
|
| Rate for Payer: Ohio Health Group HMO |
$523.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$139.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$90.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$216.38
|
| Rate for Payer: PHCS Commercial |
$670.08
|
| Rate for Payer: United Healthcare All Payer |
$614.24
|
|
|
DUCTOGRAM MULTI DUCT S&I(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
402P0086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$26.25 |
| Max. Negotiated Rate |
$214.74 |
| Rate for Payer: Aetna Commercial |
$159.20
|
| Rate for Payer: Anthem Medicaid |
$100.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$214.74
|
| Rate for Payer: Healthspan PPO |
$149.18
|
| Rate for Payer: Humana Medicaid |
$100.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$29.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$102.76
|
| Rate for Payer: Molina Healthcare Passport |
$100.75
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$101.76
|
|
|
DUCTOGRAM MULTI DUCT S&I(T
|
Facility
|
IP
|
$623.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
402T0086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$80.99 |
| Max. Negotiated Rate |
$598.08 |
| Rate for Payer: Aetna Commercial |
$479.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$485.94
|
| Rate for Payer: Cash Price |
$311.50
|
| Rate for Payer: Cigna Commercial |
$517.09
|
| Rate for Payer: First Health Commercial |
$591.85
|
| Rate for Payer: Humana Commercial |
$529.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$510.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$459.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$548.24
|
| Rate for Payer: Ohio Health Group HMO |
$467.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.13
|
| Rate for Payer: PHCS Commercial |
$598.08
|
| Rate for Payer: United Healthcare All Payer |
$548.24
|
|
|
DUCTOGRAM MULTI DUCT S&I(T
|
Facility
|
OP
|
$623.00
|
|
|
Service Code
|
HCPCS 77054
|
| Hospital Charge Code |
402T0086
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$80.99 |
| Max. Negotiated Rate |
$598.08 |
| Rate for Payer: Aetna Commercial |
$479.71
|
| Rate for Payer: Anthem Medicaid |
$214.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$485.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$311.50
|
| Rate for Payer: Cash Price |
$311.50
|
| Rate for Payer: Cigna Commercial |
$517.09
|
| Rate for Payer: First Health Commercial |
$591.85
|
| Rate for Payer: Humana Commercial |
$529.55
|
| Rate for Payer: Humana KY Medicaid |
$214.25
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$216.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$510.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$459.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$218.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$548.24
|
| Rate for Payer: Ohio Health Group HMO |
$467.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.13
|
| Rate for Payer: PHCS Commercial |
$598.08
|
| Rate for Payer: United Healthcare All Payer |
$548.24
|
|
|
DUCTOGRAM SINGLE DUCT S&I
|
Facility
|
IP
|
$676.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
40200085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$87.88 |
| Max. Negotiated Rate |
$648.96 |
| Rate for Payer: Aetna Commercial |
$520.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$527.28
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$561.08
|
| Rate for Payer: First Health Commercial |
$642.20
|
| Rate for Payer: Humana Commercial |
$574.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$554.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.88
|
| Rate for Payer: Ohio Health Group HMO |
$507.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.56
|
| Rate for Payer: PHCS Commercial |
$648.96
|
| Rate for Payer: United Healthcare All Payer |
$594.88
|
|
|
DUCTOGRAM SINGLE DUCT S&I
|
Professional
|
Both
|
$676.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
40200085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$22.39 |
| Max. Negotiated Rate |
$676.00 |
| Rate for Payer: Aetna Commercial |
$118.33
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$676.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$149.83
|
| Rate for Payer: Healthspan PPO |
$110.88
|
| Rate for Payer: Humana Medicaid |
$70.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.91
|
| Rate for Payer: Molina Healthcare Passport |
$70.50
|
| Rate for Payer: Multiplan PHCS |
$405.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$473.20
|
| Rate for Payer: UHCCP Medicaid |
$236.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.20
|
|
|
DUCTOGRAM SINGLE DUCT S&I
|
Facility
|
OP
|
$676.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
40200085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$87.88 |
| Max. Negotiated Rate |
$648.96 |
| Rate for Payer: Aetna Commercial |
$520.52
|
| Rate for Payer: Anthem Medicaid |
$232.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$527.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cash Price |
$338.00
|
| Rate for Payer: Cigna Commercial |
$561.08
|
| Rate for Payer: First Health Commercial |
$642.20
|
| Rate for Payer: Humana Commercial |
$574.60
|
| Rate for Payer: Humana KY Medicaid |
$232.48
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$234.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$554.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$237.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.88
|
| Rate for Payer: Ohio Health Group HMO |
$507.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.56
|
| Rate for Payer: PHCS Commercial |
$648.96
|
| Rate for Payer: United Healthcare All Payer |
$594.88
|
|
|
DUCTOGRAM SINGLE DUCT S&I(P
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
402P0085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$22.39 |
| Max. Negotiated Rate |
$149.83 |
| Rate for Payer: Aetna Commercial |
$118.33
|
| Rate for Payer: Anthem Medicaid |
$70.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$149.83
|
| Rate for Payer: Healthspan PPO |
$110.88
|
| Rate for Payer: Humana Medicaid |
$70.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.91
|
| Rate for Payer: Molina Healthcare Passport |
$70.50
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.20
|
|
|
DUCTOGRAM SINGLE DUCT S&I(T
|
Facility
|
IP
|
$601.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
402T0085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.13 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.31
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
DUCTOGRAM SINGLE DUCT S&I(T
|
Facility
|
OP
|
$601.00
|
|
|
Service Code
|
HCPCS 77053
|
| Hospital Charge Code |
402T0085
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.13 |
| Max. Negotiated Rate |
$576.96 |
| Rate for Payer: Aetna Commercial |
$462.77
|
| Rate for Payer: Anthem Medicaid |
$206.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$211.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$296.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$286.06
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cash Price |
$300.50
|
| Rate for Payer: Cigna Commercial |
$498.83
|
| Rate for Payer: First Health Commercial |
$570.95
|
| Rate for Payer: Humana Commercial |
$510.85
|
| Rate for Payer: Humana KY Medicaid |
$206.68
|
| Rate for Payer: Humana Medicare Advantage |
$211.90
|
| Rate for Payer: Kentucky WC Medicaid |
$208.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.88
|
| Rate for Payer: Ohio Health Group HMO |
$450.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.31
|
| Rate for Payer: PHCS Commercial |
$576.96
|
| Rate for Payer: United Healthcare All Payer |
$528.88
|
|
|
DULCOLAX (BISACODYL) 5MG/1TAB
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 904640761
|
| Hospital Charge Code |
25000582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
DULCOLAX (BISACODYL) 5MG/1TAB
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 904640761
|
| Hospital Charge Code |
25000582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.06 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.51
|
| Rate for Payer: First Health Commercial |
$4.02
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.72
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Payer |
$3.72
|
|
|
DUODENOTOMY - FOR EXPLORATION
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
76101803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$490.98 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna Commercial |
$1,240.43
|
| Rate for Payer: Anthem Medicaid |
$490.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,850.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,147.34
|
| Rate for Payer: Healthspan PPO |
$1,046.07
|
| Rate for Payer: Humana Medicaid |
$490.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,103.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$500.80
|
| Rate for Payer: Molina Healthcare Passport |
$490.98
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,295.00
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$495.89
|
|
|
DUODENOTOMY - FOR EXPLORATION
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
76101803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.50 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$370.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
DUODENOTOMY - FOR EXPLORATION
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
76101803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.50 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem Medicaid |
$636.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Humana KY Medicaid |
$636.22
|
| Rate for Payer: Kentucky WC Medicaid |
$642.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$648.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$370.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
DUODENOTOMY - FOR EXPLORATIO(P
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44010
|
| Hospital Charge Code |
761P1803
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$490.98 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna Commercial |
$1,240.43
|
| Rate for Payer: Anthem Medicaid |
$490.98
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,850.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,147.34
|
| Rate for Payer: Healthspan PPO |
$1,046.07
|
| Rate for Payer: Humana Medicaid |
$490.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,103.53
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$500.80
|
| Rate for Payer: Molina Healthcare Passport |
$490.98
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,295.00
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$495.89
|
|
|
DUONEB NEB [3 ML]
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
25003033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
DUONEB NEB [3 ML]
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
HCPCS J7620
|
| Hospital Charge Code |
25003033
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
DUOVISC 0.55-0.5ML KIT
|
Facility
|
OP
|
$845.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004416
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.85 |
| Max. Negotiated Rate |
$811.21 |
| Rate for Payer: Aetna Commercial |
$650.66
|
| Rate for Payer: Anthem Medicaid |
$290.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$659.11
|
| Rate for Payer: Cash Price |
$422.50
|
| Rate for Payer: Cigna Commercial |
$701.36
|
| Rate for Payer: First Health Commercial |
$802.76
|
| Rate for Payer: Humana Commercial |
$718.26
|
| Rate for Payer: Humana KY Medicaid |
$290.60
|
| Rate for Payer: Kentucky WC Medicaid |
$293.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$692.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$623.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$296.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$743.61
|
| Rate for Payer: Ohio Health Group HMO |
$633.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.95
|
| Rate for Payer: PHCS Commercial |
$811.21
|
| Rate for Payer: United Healthcare All Payer |
$743.61
|
|
|
DUOVISC 0.55-0.5ML KIT
|
Facility
|
IP
|
$845.01
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004416
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$109.85 |
| Max. Negotiated Rate |
$811.21 |
| Rate for Payer: Aetna Commercial |
$650.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$659.11
|
| Rate for Payer: Cash Price |
$422.50
|
| Rate for Payer: Cigna Commercial |
$701.36
|
| Rate for Payer: First Health Commercial |
$802.76
|
| Rate for Payer: Humana Commercial |
$718.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$692.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$623.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$253.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$743.61
|
| Rate for Payer: Ohio Health Group HMO |
$633.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$261.95
|
| Rate for Payer: PHCS Commercial |
$811.21
|
| Rate for Payer: United Healthcare All Payer |
$743.61
|
|
|
DUOVISC 0.5mL/0.85mL KIT
|
Facility
|
IP
|
$895.49
|
|
|
Service Code
|
NDC 8065199907
|
| Hospital Charge Code |
25004423
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.41 |
| Max. Negotiated Rate |
$859.67 |
| Rate for Payer: Aetna Commercial |
$689.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$698.48
|
| Rate for Payer: Cash Price |
$447.74
|
| Rate for Payer: Cigna Commercial |
$743.26
|
| Rate for Payer: First Health Commercial |
$850.72
|
| Rate for Payer: Humana Commercial |
$761.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$734.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$660.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$788.03
|
| Rate for Payer: Ohio Health Group HMO |
$671.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$179.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$277.60
|
| Rate for Payer: PHCS Commercial |
$859.67
|
| Rate for Payer: United Healthcare All Payer |
$788.03
|
|
|
DUOVISC 0.5mL/0.85mL KIT
|
Facility
|
OP
|
$895.49
|
|
|
Service Code
|
NDC 8065199907
|
| Hospital Charge Code |
25004423
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$116.41 |
| Max. Negotiated Rate |
$859.67 |
| Rate for Payer: Aetna Commercial |
$689.53
|
| Rate for Payer: Anthem Medicaid |
$307.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$698.48
|
| Rate for Payer: Cash Price |
$447.74
|
| Rate for Payer: Cigna Commercial |
$743.26
|
| Rate for Payer: First Health Commercial |
$850.72
|
| Rate for Payer: Humana Commercial |
$761.17
|
| Rate for Payer: Humana KY Medicaid |
$307.96
|
| Rate for Payer: Kentucky WC Medicaid |
$311.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$734.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$660.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$268.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$314.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$788.03
|
| Rate for Payer: Ohio Health Group HMO |
$671.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$179.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$277.60
|
| Rate for Payer: PHCS Commercial |
$859.67
|
| Rate for Payer: United Healthcare All Payer |
$788.03
|
|
