|
EMP STEM 9 RO 140MM
|
Facility
|
IP
|
$17,679.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.31 |
| Max. Negotiated Rate |
$16,972.13 |
| Rate for Payer: Aetna Commercial |
$13,613.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.85
|
| Rate for Payer: Cash Price |
$8,839.65
|
| Rate for Payer: Cigna Commercial |
$14,673.82
|
| Rate for Payer: First Health Commercial |
$16,795.34
|
| Rate for Payer: Humana Commercial |
$15,027.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,497.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,047.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,557.78
|
| Rate for Payer: Ohio Health Group HMO |
$13,259.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.58
|
| Rate for Payer: PHCS Commercial |
$16,972.13
|
| Rate for Payer: United Healthcare All Payer |
$15,557.78
|
|
|
EMP STEM 9 RO 140MM
|
Facility
|
OP
|
$17,679.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.31 |
| Max. Negotiated Rate |
$16,972.13 |
| Rate for Payer: Aetna Commercial |
$13,613.06
|
| Rate for Payer: Anthem Medicaid |
$6,079.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.85
|
| Rate for Payer: Cash Price |
$8,839.65
|
| Rate for Payer: Cigna Commercial |
$14,673.82
|
| Rate for Payer: First Health Commercial |
$16,795.34
|
| Rate for Payer: Humana Commercial |
$15,027.40
|
| Rate for Payer: Humana KY Medicaid |
$6,079.91
|
| Rate for Payer: Kentucky WC Medicaid |
$6,141.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,497.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,047.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,201.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,557.78
|
| Rate for Payer: Ohio Health Group HMO |
$13,259.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.58
|
| Rate for Payer: PHCS Commercial |
$16,972.13
|
| Rate for Payer: United Healthcare All Payer |
$15,557.78
|
|
|
EMP STEM 9 SO 140MM
|
Facility
|
IP
|
$17,679.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.31 |
| Max. Negotiated Rate |
$16,972.13 |
| Rate for Payer: Aetna Commercial |
$13,613.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.85
|
| Rate for Payer: Cash Price |
$8,839.65
|
| Rate for Payer: Cigna Commercial |
$14,673.82
|
| Rate for Payer: First Health Commercial |
$16,795.34
|
| Rate for Payer: Humana Commercial |
$15,027.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,497.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,047.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,557.78
|
| Rate for Payer: Ohio Health Group HMO |
$13,259.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.58
|
| Rate for Payer: PHCS Commercial |
$16,972.13
|
| Rate for Payer: United Healthcare All Payer |
$15,557.78
|
|
|
EMP STEM 9 SO 140MM
|
Facility
|
OP
|
$17,679.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,298.31 |
| Max. Negotiated Rate |
$16,972.13 |
| Rate for Payer: Aetna Commercial |
$13,613.06
|
| Rate for Payer: Anthem Medicaid |
$6,079.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,789.85
|
| Rate for Payer: Cash Price |
$8,839.65
|
| Rate for Payer: Cigna Commercial |
$14,673.82
|
| Rate for Payer: First Health Commercial |
$16,795.34
|
| Rate for Payer: Humana Commercial |
$15,027.40
|
| Rate for Payer: Humana KY Medicaid |
$6,079.91
|
| Rate for Payer: Kentucky WC Medicaid |
$6,141.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,497.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,047.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,303.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,201.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,557.78
|
| Rate for Payer: Ohio Health Group HMO |
$13,259.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,535.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,298.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,480.58
|
| Rate for Payer: PHCS Commercial |
$16,972.13
|
| Rate for Payer: United Healthcare All Payer |
$15,557.78
|
|
|
EMSAM(SELEGILINE)24HR 6MG PTCH
|
Facility
|
IP
|
$143.50
|
|
|
Service Code
|
NDC 49502090030
|
| Hospital Charge Code |
25000618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.66 |
| Max. Negotiated Rate |
$137.76 |
| Rate for Payer: Aetna Commercial |
$110.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.93
|
| Rate for Payer: Cash Price |
$71.75
|
| Rate for Payer: Cigna Commercial |
$119.10
|
| Rate for Payer: First Health Commercial |
$136.32
|
| Rate for Payer: Humana Commercial |
$121.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.28
|
| Rate for Payer: Ohio Health Group HMO |
$107.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.48
|
| Rate for Payer: PHCS Commercial |
$137.76
|
| Rate for Payer: United Healthcare All Payer |
$126.28
|
|
|
EMSAM(SELEGILINE)24HR 6MG PTCH
|
Facility
|
OP
|
$143.50
|
|
|
Service Code
|
NDC 49502090030
|
| Hospital Charge Code |
25000618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.66 |
| Max. Negotiated Rate |
$137.76 |
| Rate for Payer: Aetna Commercial |
$110.50
|
| Rate for Payer: Anthem Medicaid |
$49.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.93
|
| Rate for Payer: Cash Price |
$71.75
|
| Rate for Payer: Cigna Commercial |
$119.10
|
| Rate for Payer: First Health Commercial |
$136.32
|
| Rate for Payer: Humana Commercial |
$121.98
|
| Rate for Payer: Humana KY Medicaid |
$49.35
|
| Rate for Payer: Kentucky WC Medicaid |
$49.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.28
|
| Rate for Payer: Ohio Health Group HMO |
$107.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.48
|
| Rate for Payer: PHCS Commercial |
$137.76
|
| Rate for Payer: United Healthcare All Payer |
$126.28
|
|
|
EMTRIVA 200 MG CAPSULE
|
Facility
|
IP
|
$34.88
|
|
|
Service Code
|
NDC 61958060101
|
| Hospital Charge Code |
25003036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$33.48 |
| Rate for Payer: Aetna Commercial |
$26.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.21
|
| Rate for Payer: Cash Price |
$17.44
|
| Rate for Payer: Cigna Commercial |
$28.95
|
| Rate for Payer: First Health Commercial |
$33.14
|
| Rate for Payer: Humana Commercial |
$29.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.69
|
| Rate for Payer: Ohio Health Group HMO |
$26.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.81
|
| Rate for Payer: PHCS Commercial |
$33.48
|
| Rate for Payer: United Healthcare All Payer |
$30.69
|
|
|
EMTRIVA 200 MG CAPSULE
|
Facility
|
OP
|
$34.88
|
|
|
Service Code
|
NDC 61958060101
|
| Hospital Charge Code |
25003036
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.53 |
| Max. Negotiated Rate |
$33.48 |
| Rate for Payer: Aetna Commercial |
$26.86
|
| Rate for Payer: Anthem Medicaid |
$12.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.21
|
| Rate for Payer: Cash Price |
$17.44
|
| Rate for Payer: Cigna Commercial |
$28.95
|
| Rate for Payer: First Health Commercial |
$33.14
|
| Rate for Payer: Humana Commercial |
$29.65
|
| Rate for Payer: Humana KY Medicaid |
$12.00
|
| Rate for Payer: Kentucky WC Medicaid |
$12.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.69
|
| Rate for Payer: Ohio Health Group HMO |
$26.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.81
|
| Rate for Payer: PHCS Commercial |
$33.48
|
| Rate for Payer: United Healthcare All Payer |
$30.69
|
|
|
ENABLEX 15MG TABLET
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
NDC 33342027707
|
| Hospital Charge Code |
25000619
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
ENABLEX 15MG TABLET
|
Facility
|
IP
|
$10.17
|
|
|
Service Code
|
NDC 33342027707
|
| Hospital Charge Code |
25000619
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
ENABLEX(DARIFEN HYDRO)7.5 MG T
|
Facility
|
OP
|
$10.17
|
|
|
Service Code
|
NDC 69097043102
|
| Hospital Charge Code |
25000620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
|
|
ENABLEX(DARIFEN HYDRO)7.5 MG T
|
Facility
|
IP
|
$10.17
|
|
|
Service Code
|
NDC 69097043102
|
| Hospital Charge Code |
25000620
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.76 |
| Rate for Payer: Aetna Commercial |
$7.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.93
|
| Rate for Payer: Cash Price |
$5.08
|
| Rate for Payer: Cigna Commercial |
$8.44
|
| Rate for Payer: First Health Commercial |
$9.66
|
| Rate for Payer: Humana Commercial |
$8.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.95
|
| Rate for Payer: Ohio Health Group HMO |
$7.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$9.76
|
| Rate for Payer: United Healthcare All Payer |
$8.95
|
|
|
ENBREL 25MG (50MG/ML) DISP SYR
|
Facility
|
IP
|
$3,655.98
|
|
|
Service Code
|
HCPCS J1438
|
| Hospital Charge Code |
25002056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$475.28 |
| Max. Negotiated Rate |
$3,509.74 |
| Rate for Payer: Aetna Commercial |
$2,815.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,851.66
|
| Rate for Payer: Cash Price |
$1,827.99
|
| Rate for Payer: Cigna Commercial |
$3,034.46
|
| Rate for Payer: First Health Commercial |
$3,473.18
|
| Rate for Payer: Humana Commercial |
$3,107.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,997.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,698.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,096.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,217.26
|
| Rate for Payer: Ohio Health Group HMO |
$2,741.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$731.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$475.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,133.35
|
| Rate for Payer: PHCS Commercial |
$3,509.74
|
| Rate for Payer: United Healthcare All Payer |
$3,217.26
|
|
|
ENBREL 25MG (50MG/ML) DISP SYR
|
Facility
|
OP
|
$3,655.98
|
|
|
Service Code
|
HCPCS J1438
|
| Hospital Charge Code |
25002056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$475.28 |
| Max. Negotiated Rate |
$3,509.74 |
| Rate for Payer: Aetna Commercial |
$2,815.10
|
| Rate for Payer: Anthem Medicaid |
$1,257.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$790.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,851.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,107.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,067.55
|
| Rate for Payer: Cash Price |
$1,827.99
|
| Rate for Payer: Cash Price |
$1,827.99
|
| Rate for Payer: Cigna Commercial |
$3,034.46
|
| Rate for Payer: First Health Commercial |
$3,473.18
|
| Rate for Payer: Humana Commercial |
$3,107.58
|
| Rate for Payer: Humana KY Medicaid |
$1,257.29
|
| Rate for Payer: Humana Medicare Advantage |
$790.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,270.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,997.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,698.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,282.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,217.26
|
| Rate for Payer: Ohio Health Group HMO |
$2,741.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$731.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$475.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,133.35
|
| Rate for Payer: PHCS Commercial |
$3,509.74
|
| Rate for Payer: United Healthcare All Payer |
$3,217.26
|
|
|
ENDCAP INPINGING NON STERILE
|
Facility
|
IP
|
$2,060.50
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$267.86 |
| Max. Negotiated Rate |
$1,978.08 |
| Rate for Payer: Aetna Commercial |
$1,586.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,607.19
|
| Rate for Payer: Cash Price |
$1,030.25
|
| Rate for Payer: Cigna Commercial |
$1,710.22
|
| Rate for Payer: First Health Commercial |
$1,957.48
|
| Rate for Payer: Humana Commercial |
$1,751.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,813.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$267.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$638.76
|
| Rate for Payer: PHCS Commercial |
$1,978.08
|
| Rate for Payer: United Healthcare All Payer |
$1,813.24
|
|
|
ENDCAP INPINGING NON STERILE
|
Facility
|
OP
|
$2,060.50
|
|
|
Service Code
|
HCPCS C1764
|
| Hospital Charge Code |
27000049
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$267.86 |
| Max. Negotiated Rate |
$1,978.08 |
| Rate for Payer: Aetna Commercial |
$1,586.58
|
| Rate for Payer: Anthem Medicaid |
$708.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,607.19
|
| Rate for Payer: Cash Price |
$1,030.25
|
| Rate for Payer: Cigna Commercial |
$1,710.22
|
| Rate for Payer: First Health Commercial |
$1,957.48
|
| Rate for Payer: Humana Commercial |
$1,751.42
|
| Rate for Payer: Humana KY Medicaid |
$708.61
|
| Rate for Payer: Kentucky WC Medicaid |
$715.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,813.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$267.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$638.76
|
| Rate for Payer: PHCS Commercial |
$1,978.08
|
| Rate for Payer: United Healthcare All Payer |
$1,813.24
|
|
|
ENDO-AVITENE 10MM SHEET
|
Facility
|
IP
|
$370.00
|
|
|
Service Code
|
NDC 53276101015
|
| Hospital Charge Code |
27000238
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.10 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.70
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
ENDO-AVITENE 10MM SHEET
|
Facility
|
OP
|
$370.00
|
|
|
Service Code
|
NDC 53276101015
|
| Hospital Charge Code |
27000238
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.10 |
| Max. Negotiated Rate |
$355.20 |
| Rate for Payer: Aetna Commercial |
$284.90
|
| Rate for Payer: Anthem Medicaid |
$127.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$288.60
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$307.10
|
| Rate for Payer: First Health Commercial |
$351.50
|
| Rate for Payer: Humana Commercial |
$314.50
|
| Rate for Payer: Humana KY Medicaid |
$127.24
|
| Rate for Payer: Kentucky WC Medicaid |
$128.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$303.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$273.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$129.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$325.60
|
| Rate for Payer: Ohio Health Group HMO |
$277.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.70
|
| Rate for Payer: PHCS Commercial |
$355.20
|
| Rate for Payer: United Healthcare All Payer |
$325.60
|
|
|
ENDOCERV CURETTAGE W/SCOPE
|
Facility
|
OP
|
$931.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
76102196
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.03 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem Medicaid |
$320.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$277.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$388.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$374.52
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Humana KY Medicaid |
$320.17
|
| Rate for Payer: Humana Medicare Advantage |
$277.42
|
| Rate for Payer: Kentucky WC Medicaid |
$323.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.61
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
ENDOCERV CURETTAGE W/SCOPE
|
Facility
|
IP
|
$931.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
76102196
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$121.03 |
| Max. Negotiated Rate |
$893.76 |
| Rate for Payer: Aetna Commercial |
$716.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.18
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$772.73
|
| Rate for Payer: First Health Commercial |
$884.45
|
| Rate for Payer: Humana Commercial |
$791.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$763.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$279.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$819.28
|
| Rate for Payer: Ohio Health Group HMO |
$698.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$288.61
|
| Rate for Payer: PHCS Commercial |
$893.76
|
| Rate for Payer: United Healthcare All Payer |
$819.28
|
|
|
ENDOCERV CURETTAGE W/SCOPE
|
Professional
|
Both
|
$931.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
76102196
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.79 |
| Max. Negotiated Rate |
$931.00 |
| Rate for Payer: Aetna Commercial |
$159.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$70.79
|
| Rate for Payer: Anthem Medicaid |
$78.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$931.00
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cigna Commercial |
$203.90
|
| Rate for Payer: Healthspan PPO |
$197.35
|
| Rate for Payer: Humana Medicaid |
$78.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$135.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.77
|
| Rate for Payer: Molina Healthcare Passport |
$78.21
|
| Rate for Payer: Multiplan PHCS |
$558.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$651.70
|
| Rate for Payer: UHCCP Medicaid |
$74.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.99
|
|
|
ENDOCERV CURETTAGE W/SCOPE(P
|
Professional
|
Both
|
$390.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
761P2196
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.79 |
| Max. Negotiated Rate |
$390.00 |
| Rate for Payer: Aetna Commercial |
$159.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$70.79
|
| Rate for Payer: Anthem Medicaid |
$78.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$390.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cash Price |
$195.00
|
| Rate for Payer: Cigna Commercial |
$203.90
|
| Rate for Payer: Healthspan PPO |
$197.35
|
| Rate for Payer: Humana Medicaid |
$78.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$135.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.77
|
| Rate for Payer: Molina Healthcare Passport |
$78.21
|
| Rate for Payer: Multiplan PHCS |
$234.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$273.00
|
| Rate for Payer: UHCCP Medicaid |
$74.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.99
|
|
|
ENDOCERV CURETTAGE W/SCOPE(T
|
Facility
|
OP
|
$541.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
761T2196
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.33 |
| Max. Negotiated Rate |
$519.36 |
| Rate for Payer: Aetna Commercial |
$416.57
|
| Rate for Payer: Anthem Medicaid |
$186.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$277.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$388.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$374.52
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cigna Commercial |
$449.03
|
| Rate for Payer: First Health Commercial |
$513.95
|
| Rate for Payer: Humana Commercial |
$459.85
|
| Rate for Payer: Humana KY Medicaid |
$186.05
|
| Rate for Payer: Humana Medicare Advantage |
$277.42
|
| Rate for Payer: Kentucky WC Medicaid |
$187.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$443.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.08
|
| Rate for Payer: Ohio Health Group HMO |
$405.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.71
|
| Rate for Payer: PHCS Commercial |
$519.36
|
| Rate for Payer: United Healthcare All Payer |
$476.08
|
|
|
ENDOCERV CURETTAGE W/SCOPE(T
|
Facility
|
IP
|
$541.00
|
|
|
Service Code
|
HCPCS 57456
|
| Hospital Charge Code |
761T2196
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.33 |
| Max. Negotiated Rate |
$519.36 |
| Rate for Payer: Aetna Commercial |
$416.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.98
|
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Cigna Commercial |
$449.03
|
| Rate for Payer: First Health Commercial |
$513.95
|
| Rate for Payer: Humana Commercial |
$459.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$443.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$399.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$476.08
|
| Rate for Payer: Ohio Health Group HMO |
$405.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$167.71
|
| Rate for Payer: PHCS Commercial |
$519.36
|
| Rate for Payer: United Healthcare All Payer |
$476.08
|
|
|
ENDOCERVICAL CURETTAGE
|
Facility
|
OP
|
$2,057.21
|
|
|
Service Code
|
HCPCS 57505
|
| Hospital Charge Code |
76102199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$267.44 |
| Max. Negotiated Rate |
$1,974.92 |
| Rate for Payer: Aetna Commercial |
$1,584.05
|
| Rate for Payer: Anthem Medicaid |
$707.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$695.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,604.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$973.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$938.51
|
| Rate for Payer: Cash Price |
$1,028.61
|
| Rate for Payer: Cash Price |
$1,028.61
|
| Rate for Payer: Cigna Commercial |
$1,707.48
|
| Rate for Payer: First Health Commercial |
$1,954.35
|
| Rate for Payer: Humana Commercial |
$1,748.63
|
| Rate for Payer: Humana KY Medicaid |
$707.47
|
| Rate for Payer: Humana Medicare Advantage |
$695.19
|
| Rate for Payer: Kentucky WC Medicaid |
$714.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,686.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,518.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$834.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$721.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,810.34
|
| Rate for Payer: Ohio Health Group HMO |
$1,542.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$411.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$267.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$637.74
|
| Rate for Payer: PHCS Commercial |
$1,974.92
|
| Rate for Payer: United Healthcare All Payer |
$1,810.34
|
|
