|
AGC TIBIAL MOLD 70MM
|
Facility
|
OP
|
$7,409.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.76 |
| Max. Negotiated Rate |
$7,112.83 |
| Rate for Payer: Aetna Commercial |
$5,705.08
|
| Rate for Payer: Anthem Medicaid |
$2,548.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,779.18
|
| Rate for Payer: Cash Price |
$3,704.60
|
| Rate for Payer: Cigna Commercial |
$6,149.64
|
| Rate for Payer: First Health Commercial |
$7,038.74
|
| Rate for Payer: Humana Commercial |
$6,297.82
|
| Rate for Payer: Humana KY Medicaid |
$2,548.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,573.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,075.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,467.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,222.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,599.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,520.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,556.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,927.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,446.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,112.35
|
| Rate for Payer: PHCS Commercial |
$7,112.83
|
| Rate for Payer: United Healthcare All Payer |
$6,520.10
|
|
|
AGC TIBIAL MOLD 70MM
|
Facility
|
IP
|
$7,409.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.76 |
| Max. Negotiated Rate |
$7,112.83 |
| Rate for Payer: Aetna Commercial |
$5,705.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,779.18
|
| Rate for Payer: Cash Price |
$3,704.60
|
| Rate for Payer: Cigna Commercial |
$6,149.64
|
| Rate for Payer: First Health Commercial |
$7,038.74
|
| Rate for Payer: Humana Commercial |
$6,297.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,075.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,467.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,222.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,520.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,556.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,927.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,446.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,112.35
|
| Rate for Payer: PHCS Commercial |
$7,112.83
|
| Rate for Payer: United Healthcare All Payer |
$6,520.10
|
|
|
AGC TIBIAL MOLD 75MM
|
Facility
|
OP
|
$7,409.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.76 |
| Max. Negotiated Rate |
$7,112.83 |
| Rate for Payer: Aetna Commercial |
$5,705.08
|
| Rate for Payer: Anthem Medicaid |
$2,548.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,779.18
|
| Rate for Payer: Cash Price |
$3,704.60
|
| Rate for Payer: Cigna Commercial |
$6,149.64
|
| Rate for Payer: First Health Commercial |
$7,038.74
|
| Rate for Payer: Humana Commercial |
$6,297.82
|
| Rate for Payer: Humana KY Medicaid |
$2,548.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,573.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,075.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,467.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,222.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,599.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,520.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,556.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,927.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,446.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,112.35
|
| Rate for Payer: PHCS Commercial |
$7,112.83
|
| Rate for Payer: United Healthcare All Payer |
$6,520.10
|
|
|
AGC TIBIAL MOLD 75MM
|
Facility
|
IP
|
$7,409.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.76 |
| Max. Negotiated Rate |
$7,112.83 |
| Rate for Payer: Aetna Commercial |
$5,705.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,779.18
|
| Rate for Payer: Cash Price |
$3,704.60
|
| Rate for Payer: Cigna Commercial |
$6,149.64
|
| Rate for Payer: First Health Commercial |
$7,038.74
|
| Rate for Payer: Humana Commercial |
$6,297.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,075.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,467.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,222.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,520.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,556.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,927.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,446.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,112.35
|
| Rate for Payer: PHCS Commercial |
$7,112.83
|
| Rate for Payer: United Healthcare All Payer |
$6,520.10
|
|
|
AGC TIBIAL MOLD 80MM
|
Facility
|
OP
|
$7,409.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.76 |
| Max. Negotiated Rate |
$7,112.83 |
| Rate for Payer: Aetna Commercial |
$5,705.08
|
| Rate for Payer: Anthem Medicaid |
$2,548.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,779.18
|
| Rate for Payer: Cash Price |
$3,704.60
|
| Rate for Payer: Cigna Commercial |
$6,149.64
|
| Rate for Payer: First Health Commercial |
$7,038.74
|
| Rate for Payer: Humana Commercial |
$6,297.82
|
| Rate for Payer: Humana KY Medicaid |
$2,548.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,573.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,075.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,467.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,222.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,599.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,520.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,556.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,927.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,446.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,112.35
|
| Rate for Payer: PHCS Commercial |
$7,112.83
|
| Rate for Payer: United Healthcare All Payer |
$6,520.10
|
|
|
AGC TIBIAL MOLD 80MM
|
Facility
|
IP
|
$7,409.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,222.76 |
| Max. Negotiated Rate |
$7,112.83 |
| Rate for Payer: Aetna Commercial |
$5,705.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,779.18
|
| Rate for Payer: Cash Price |
$3,704.60
|
| Rate for Payer: Cigna Commercial |
$6,149.64
|
| Rate for Payer: First Health Commercial |
$7,038.74
|
| Rate for Payer: Humana Commercial |
$6,297.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,075.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,467.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,222.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,520.10
|
| Rate for Payer: Ohio Health Group HMO |
$5,556.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,927.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,446.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,112.35
|
| Rate for Payer: PHCS Commercial |
$7,112.83
|
| Rate for Payer: United Healthcare All Payer |
$6,520.10
|
|
|
AGENT DCB 2.00*12MM
|
Facility
|
IP
|
$26,187.50
|
|
|
Service Code
|
HCPCS C9610
|
| Hospital Charge Code |
27000294
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,856.25 |
| Max. Negotiated Rate |
$25,140.00 |
| Rate for Payer: Aetna Commercial |
$20,164.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,426.25
|
| Rate for Payer: Cash Price |
$13,093.75
|
| Rate for Payer: Cigna Commercial |
$21,735.62
|
| Rate for Payer: First Health Commercial |
$24,878.12
|
| Rate for Payer: Humana Commercial |
$22,259.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,473.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,326.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,856.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,045.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,640.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,783.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,069.38
|
| Rate for Payer: PHCS Commercial |
$25,140.00
|
| Rate for Payer: United Healthcare All Payer |
$23,045.00
|
|
|
AGENT DCB 2.00*12MM
|
Facility
|
OP
|
$26,187.50
|
|
|
Service Code
|
HCPCS C9610
|
| Hospital Charge Code |
27000294
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,856.25 |
| Max. Negotiated Rate |
$25,140.00 |
| Rate for Payer: Aetna Commercial |
$20,164.38
|
| Rate for Payer: Anthem Medicaid |
$9,005.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,426.25
|
| Rate for Payer: Cash Price |
$13,093.75
|
| Rate for Payer: Cigna Commercial |
$21,735.62
|
| Rate for Payer: First Health Commercial |
$24,878.12
|
| Rate for Payer: Humana Commercial |
$22,259.38
|
| Rate for Payer: Humana KY Medicaid |
$9,005.88
|
| Rate for Payer: Kentucky WC Medicaid |
$9,097.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,473.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,326.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,856.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,186.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,045.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,640.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,783.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,069.38
|
| Rate for Payer: PHCS Commercial |
$25,140.00
|
| Rate for Payer: United Healthcare All Payer |
$23,045.00
|
|
|
AGENT DCB 4.00*20MM
|
Facility
|
OP
|
$26,187.50
|
|
|
Service Code
|
HCPCS C9610
|
| Hospital Charge Code |
27000294
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,856.25 |
| Max. Negotiated Rate |
$25,140.00 |
| Rate for Payer: Aetna Commercial |
$20,164.38
|
| Rate for Payer: Anthem Medicaid |
$9,005.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,426.25
|
| Rate for Payer: Cash Price |
$13,093.75
|
| Rate for Payer: Cigna Commercial |
$21,735.62
|
| Rate for Payer: First Health Commercial |
$24,878.12
|
| Rate for Payer: Humana Commercial |
$22,259.38
|
| Rate for Payer: Humana KY Medicaid |
$9,005.88
|
| Rate for Payer: Kentucky WC Medicaid |
$9,097.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,473.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,326.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,856.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,186.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,045.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,640.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,783.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,069.38
|
| Rate for Payer: PHCS Commercial |
$25,140.00
|
| Rate for Payer: United Healthcare All Payer |
$23,045.00
|
|
|
AGENT DCB 4.00*20MM
|
Facility
|
IP
|
$26,187.50
|
|
|
Service Code
|
HCPCS C9610
|
| Hospital Charge Code |
27000294
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,856.25 |
| Max. Negotiated Rate |
$25,140.00 |
| Rate for Payer: Aetna Commercial |
$20,164.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,426.25
|
| Rate for Payer: Cash Price |
$13,093.75
|
| Rate for Payer: Cigna Commercial |
$21,735.62
|
| Rate for Payer: First Health Commercial |
$24,878.12
|
| Rate for Payer: Humana Commercial |
$22,259.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,473.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,326.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,856.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,045.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,640.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,783.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,069.38
|
| Rate for Payer: PHCS Commercial |
$25,140.00
|
| Rate for Payer: United Healthcare All Payer |
$23,045.00
|
|
|
AGGRASTAT 0.25MG 12.5 MG/250ML
|
Facility
|
IP
|
$655.05
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
25002388
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$196.51 |
| Max. Negotiated Rate |
$628.85 |
| Rate for Payer: Aetna Commercial |
$504.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.94
|
| Rate for Payer: Cash Price |
$327.52
|
| Rate for Payer: Cigna Commercial |
$543.69
|
| Rate for Payer: First Health Commercial |
$622.30
|
| Rate for Payer: Humana Commercial |
$556.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$483.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$576.44
|
| Rate for Payer: Ohio Health Group HMO |
$491.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$524.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$451.98
|
| Rate for Payer: PHCS Commercial |
$628.85
|
| Rate for Payer: United Healthcare All Payer |
$576.44
|
|
|
AGGRASTAT 0.25MG 12.5 MG/250ML
|
Facility
|
OP
|
$655.05
|
|
|
Service Code
|
HCPCS J3246
|
| Hospital Charge Code |
25002388
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$196.51 |
| Max. Negotiated Rate |
$628.85 |
| Rate for Payer: Aetna Commercial |
$504.39
|
| Rate for Payer: Anthem Medicaid |
$225.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$510.94
|
| Rate for Payer: Cash Price |
$327.52
|
| Rate for Payer: Cigna Commercial |
$543.69
|
| Rate for Payer: First Health Commercial |
$622.30
|
| Rate for Payer: Humana Commercial |
$556.79
|
| Rate for Payer: Humana KY Medicaid |
$225.27
|
| Rate for Payer: Kentucky WC Medicaid |
$227.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$537.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$483.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$196.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$229.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$576.44
|
| Rate for Payer: Ohio Health Group HMO |
$491.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$524.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$569.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$451.98
|
| Rate for Payer: PHCS Commercial |
$628.85
|
| Rate for Payer: United Healthcare All Payer |
$576.44
|
|
|
AGGRENOX 200/25MG CAPSULE
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 43598033960
|
| Hospital Charge Code |
25000173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.21
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
AGGRENOX 200/25MG CAPSULE
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 43598033960
|
| Hospital Charge Code |
25000173
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.21
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
AGGRESV ANTIAGE PRGRM KIT GBL
|
Facility
|
IP
|
$263.00
|
|
| Hospital Charge Code |
22200151
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$252.48 |
| Rate for Payer: Aetna Commercial |
$202.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$205.14
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cigna Commercial |
$218.29
|
| Rate for Payer: First Health Commercial |
$249.85
|
| Rate for Payer: Humana Commercial |
$223.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$215.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$194.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$231.44
|
| Rate for Payer: Ohio Health Group HMO |
$197.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$210.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$181.47
|
| Rate for Payer: PHCS Commercial |
$252.48
|
| Rate for Payer: United Healthcare All Payer |
$231.44
|
|
|
AGGRESV ANTIAGE PRGRM KIT GBL
|
Professional
|
Both
|
$263.00
|
|
| Hospital Charge Code |
22200151
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$92.05 |
| Max. Negotiated Rate |
$184.10 |
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Multiplan PHCS |
$157.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$184.10
|
| Rate for Payer: UHCCP Medicaid |
$92.05
|
|
|
AGGRESV ANTIAGE PRGRM KIT GBL
|
Facility
|
OP
|
$263.00
|
|
| Hospital Charge Code |
22200151
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.90 |
| Max. Negotiated Rate |
$252.48 |
| Rate for Payer: Aetna Commercial |
$202.51
|
| Rate for Payer: Anthem Medicaid |
$90.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$205.14
|
| Rate for Payer: Cash Price |
$131.50
|
| Rate for Payer: Cigna Commercial |
$218.29
|
| Rate for Payer: First Health Commercial |
$249.85
|
| Rate for Payer: Humana Commercial |
$223.55
|
| Rate for Payer: Humana KY Medicaid |
$90.45
|
| Rate for Payer: Kentucky WC Medicaid |
$91.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$215.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$194.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$78.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$92.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$231.44
|
| Rate for Payer: Ohio Health Group HMO |
$197.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$210.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$181.47
|
| Rate for Payer: PHCS Commercial |
$252.48
|
| Rate for Payer: United Healthcare All Payer |
$231.44
|
|
|
AIR CONTRAST ENEMA W/WO KUB
|
Facility
|
OP
|
$888.00
|
|
|
Service Code
|
HCPCS 74280
|
| Hospital Charge Code |
32000138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$852.48 |
| Rate for Payer: Aetna Commercial |
$683.76
|
| Rate for Payer: Anthem Medicaid |
$305.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$692.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$737.04
|
| Rate for Payer: First Health Commercial |
$843.60
|
| Rate for Payer: Humana Commercial |
$754.80
|
| Rate for Payer: Humana KY Medicaid |
$305.38
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$308.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$728.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$655.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$311.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$781.44
|
| Rate for Payer: Ohio Health Group HMO |
$666.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$772.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.72
|
| Rate for Payer: PHCS Commercial |
$852.48
|
| Rate for Payer: United Healthcare All Payer |
$781.44
|
|
|
AIR CONTRAST ENEMA W/WO KUB
|
Facility
|
IP
|
$888.00
|
|
|
Service Code
|
HCPCS 74280
|
| Hospital Charge Code |
32000138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$266.40 |
| Max. Negotiated Rate |
$852.48 |
| Rate for Payer: Aetna Commercial |
$683.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$692.64
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$737.04
|
| Rate for Payer: First Health Commercial |
$843.60
|
| Rate for Payer: Humana Commercial |
$754.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$728.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$655.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$781.44
|
| Rate for Payer: Ohio Health Group HMO |
$666.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$710.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$772.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.72
|
| Rate for Payer: PHCS Commercial |
$852.48
|
| Rate for Payer: United Healthcare All Payer |
$781.44
|
|
|
AIR CONTRAST ENEMA W/WO KUB
|
Professional
|
Both
|
$888.00
|
|
|
Service Code
|
HCPCS 74280
|
| Hospital Charge Code |
32000138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$62.67 |
| Max. Negotiated Rate |
$532.80 |
| Rate for Payer: Aetna Commercial |
$294.04
|
| Rate for Payer: Ambetter Exchange |
$194.01
|
| Rate for Payer: Anthem Medicaid |
$165.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$194.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$194.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$232.81
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cash Price |
$444.00
|
| Rate for Payer: Cigna Commercial |
$231.47
|
| Rate for Payer: Healthspan PPO |
$275.52
|
| Rate for Payer: Humana Medicaid |
$165.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$62.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$194.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.22
|
| Rate for Payer: Molina Healthcare Passport |
$165.90
|
| Rate for Payer: Multiplan PHCS |
$532.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$252.21
|
| Rate for Payer: UHCCP Medicaid |
$310.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$194.01
|
|
|
AIR CONTRAST ENEMA W/WO KUB(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 74280
|
| Hospital Charge Code |
320P0138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$52.50 |
| Max. Negotiated Rate |
$294.04 |
| Rate for Payer: Aetna Commercial |
$294.04
|
| Rate for Payer: Ambetter Exchange |
$194.01
|
| Rate for Payer: Anthem Medicaid |
$165.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$194.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$194.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$232.81
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$231.47
|
| Rate for Payer: Healthspan PPO |
$275.52
|
| Rate for Payer: Humana Medicaid |
$165.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$62.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$194.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$194.01
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$169.22
|
| Rate for Payer: Molina Healthcare Passport |
$165.90
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$252.21
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$194.01
|
|
|
AIR CONTRAST ENEMA W/WO KUB(T
|
Facility
|
OP
|
$738.00
|
|
|
Service Code
|
HCPCS 74280
|
| Hospital Charge Code |
320T0138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$164.49 |
| Max. Negotiated Rate |
$708.48 |
| Rate for Payer: Aetna Commercial |
$568.26
|
| Rate for Payer: Anthem Medicaid |
$253.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$164.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$230.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$222.06
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$612.54
|
| Rate for Payer: First Health Commercial |
$701.10
|
| Rate for Payer: Humana Commercial |
$627.30
|
| Rate for Payer: Humana KY Medicaid |
$253.80
|
| Rate for Payer: Humana Medicare Advantage |
$164.49
|
| Rate for Payer: Kentucky WC Medicaid |
$256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$605.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$544.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$197.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$258.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$649.44
|
| Rate for Payer: Ohio Health Group HMO |
$553.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$590.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$509.22
|
| Rate for Payer: PHCS Commercial |
$708.48
|
| Rate for Payer: United Healthcare All Payer |
$649.44
|
|
|
AIR CONTRAST ENEMA W/WO KUB(T
|
Facility
|
IP
|
$738.00
|
|
|
Service Code
|
HCPCS 74280
|
| Hospital Charge Code |
320T0138
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$221.40 |
| Max. Negotiated Rate |
$708.48 |
| Rate for Payer: Aetna Commercial |
$568.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Cash Price |
$369.00
|
| Rate for Payer: Cigna Commercial |
$612.54
|
| Rate for Payer: First Health Commercial |
$701.10
|
| Rate for Payer: Humana Commercial |
$627.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$605.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$544.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$221.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$649.44
|
| Rate for Payer: Ohio Health Group HMO |
$553.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$590.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$509.22
|
| Rate for Payer: PHCS Commercial |
$708.48
|
| Rate for Payer: United Healthcare All Payer |
$649.44
|
|
|
AIRWAY INHALATION TREAT
|
Facility
|
IP
|
$306.54
|
|
|
Service Code
|
HCPCS 94640
|
| Hospital Charge Code |
92000010
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$294.28 |
| Rate for Payer: Aetna Commercial |
$236.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$239.10
|
| Rate for Payer: Cash Price |
$153.27
|
| Rate for Payer: Cigna Commercial |
$254.43
|
| Rate for Payer: First Health Commercial |
$291.21
|
| Rate for Payer: Humana Commercial |
$260.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$251.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$226.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$91.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$269.76
|
| Rate for Payer: Ohio Health Group HMO |
$229.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$245.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$211.51
|
| Rate for Payer: PHCS Commercial |
$294.28
|
| Rate for Payer: United Healthcare All Payer |
$269.76
|
|
|
AIRWAY INHALATION TREAT
|
Facility
|
IP
|
$315.00
|
|
|
Service Code
|
HCPCS 94640
|
| Hospital Charge Code |
41000076
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$94.50 |
| Max. Negotiated Rate |
$302.40 |
| Rate for Payer: Aetna Commercial |
$242.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$245.70
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$261.45
|
| Rate for Payer: First Health Commercial |
$299.25
|
| Rate for Payer: Humana Commercial |
$267.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$258.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$232.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$277.20
|
| Rate for Payer: Ohio Health Group HMO |
$236.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$252.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$274.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.35
|
| Rate for Payer: PHCS Commercial |
$302.40
|
| Rate for Payer: United Healthcare All Payer |
$277.20
|
|
