|
EEG REPET STIM PAIRED STIMU(T
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
HCPCS 95937
|
| Hospital Charge Code |
922T0018
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$64.80 |
| Max. Negotiated Rate |
$207.36 |
| Rate for Payer: Aetna Commercial |
$166.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$168.48
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$179.28
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: Humana Commercial |
$183.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$177.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$159.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$190.08
|
| Rate for Payer: Ohio Health Group HMO |
$162.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$187.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$149.04
|
| Rate for Payer: PHCS Commercial |
$207.36
|
| Rate for Payer: United Healthcare All Payer |
$190.08
|
|
|
EES(ERYTHROMYCIN) 40 400MG/5ML
|
Facility
|
OP
|
$9.43
|
|
|
Service Code
|
NDC 62559063101
|
| Hospital Charge Code |
25000597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Anthem Medicaid |
$3.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: First Health Commercial |
$8.96
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Humana KY Medicaid |
$3.24
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.51
|
| Rate for Payer: PHCS Commercial |
$9.05
|
| Rate for Payer: United Healthcare All Payer |
$8.30
|
|
|
EES(ERYTHROMYCIN) 40 400MG/5ML
|
Facility
|
IP
|
$9.43
|
|
|
Service Code
|
NDC 62559063101
|
| Hospital Charge Code |
25000597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.83 |
| Max. Negotiated Rate |
$9.05 |
| Rate for Payer: Aetna Commercial |
$7.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.83
|
| Rate for Payer: First Health Commercial |
$8.96
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.51
|
| Rate for Payer: PHCS Commercial |
$9.05
|
| Rate for Payer: United Healthcare All Payer |
$8.30
|
|
|
EFFEXOR (VENLAFAXI 37.5MG/1TAB
|
Facility
|
OP
|
$5.06
|
|
|
Service Code
|
NDC 68084084401
|
| Hospital Charge Code |
25000598
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cigna Commercial |
$4.20
|
| Rate for Payer: First Health Commercial |
$4.81
|
| Rate for Payer: Humana Commercial |
$4.30
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.45
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
EFFEXOR (VENLAFAXI 37.5MG/1TAB
|
Facility
|
IP
|
$5.06
|
|
|
Service Code
|
NDC 68084084401
|
| Hospital Charge Code |
25000598
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna Commercial |
$3.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.95
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cigna Commercial |
$4.20
|
| Rate for Payer: First Health Commercial |
$4.81
|
| Rate for Payer: Humana Commercial |
$4.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.45
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.49
|
| Rate for Payer: PHCS Commercial |
$4.86
|
| Rate for Payer: United Healthcare All Payer |
$4.45
|
|
|
EFFEXOR (VENLAFAXINE 50MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 57237017401
|
| Hospital Charge Code |
25000599
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
EFFEXOR (VENLAFAXINE 50MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 57237017401
|
| Hospital Charge Code |
25000599
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
EFFEXOR XR(VENLAFAXINE) 37.5MG
|
Facility
|
OP
|
$4.69
|
|
|
Service Code
|
NDC 68084069801
|
| Hospital Charge Code |
25000600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| 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 |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
EFFEXOR XR(VENLAFAXINE) 37.5MG
|
Facility
|
IP
|
$4.69
|
|
|
Service Code
|
NDC 68084069801
|
| Hospital Charge Code |
25000600
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.50 |
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.66
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.89
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.13
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.50
|
| Rate for Payer: United Healthcare All Payer |
$4.13
|
|
|
EFFEXOR XR (VENLAFZXINE) 75MG
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 68084070901
|
| Hospital Charge Code |
25000601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
EFFEXOR XR (VENLAFZXINE) 75MG
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 68084070901
|
| Hospital Charge Code |
25000601
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
EFFIENT 10MG TABLET
|
Facility
|
OP
|
$5.03
|
|
|
Service Code
|
NDC 60505464303
|
| Hospital Charge Code |
25000602
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.78
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.43
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.47
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
EFFIENT 10MG TABLET
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
NDC 60505464303
|
| Hospital Charge Code |
25000602
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.78
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.43
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.47
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
EFFIENT 5MG TABLET
|
Facility
|
OP
|
$5.03
|
|
|
Service Code
|
NDC 60505464203
|
| Hospital Charge Code |
25000603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem Medicaid |
$1.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.78
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Humana KY Medicaid |
$1.73
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.43
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.47
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
EFFIENT 5MG TABLET
|
Facility
|
IP
|
$5.03
|
|
|
Service Code
|
NDC 60505464203
|
| Hospital Charge Code |
25000603
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.83 |
| Rate for Payer: Aetna Commercial |
$3.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.92
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.17
|
| Rate for Payer: First Health Commercial |
$4.78
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.43
|
| Rate for Payer: Ohio Health Group HMO |
$3.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.47
|
| Rate for Payer: PHCS Commercial |
$4.83
|
| Rate for Payer: United Healthcare All Payer |
$4.43
|
|
|
EGD CAUTERY TUMOR POLYP
|
Professional
|
Both
|
$875.00
|
|
|
Service Code
|
HCPCS 43250
|
| Hospital Charge Code |
76101746
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.39 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$286.74
|
| Rate for Payer: Ambetter Exchange |
$159.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.21
|
| Rate for Payer: Anthem Medicaid |
$227.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$159.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$159.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$191.27
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$261.98
|
| Rate for Payer: Healthspan PPO |
$241.81
|
| Rate for Payer: Humana Medicaid |
$227.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$159.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$232.28
|
| Rate for Payer: Molina Healthcare Passport |
$227.73
|
| Rate for Payer: Multiplan PHCS |
$525.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$207.21
|
| Rate for Payer: UHCCP Medicaid |
$169.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$230.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$159.39
|
|
|
EGD CAUTERY TUMOR POLYP
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS 43250
|
| Hospital Charge Code |
76101746
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: Aetna Commercial |
$673.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$682.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$726.25
|
| Rate for Payer: First Health Commercial |
$831.25
|
| Rate for Payer: Humana Commercial |
$743.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$717.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$770.00
|
| Rate for Payer: Ohio Health Group HMO |
$656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$761.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.75
|
| Rate for Payer: PHCS Commercial |
$840.00
|
| Rate for Payer: United Healthcare All Payer |
$770.00
|
|
|
EGD CAUTERY TUMOR POLYP
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS 43250
|
| Hospital Charge Code |
76101746
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.91 |
| Max. Negotiated Rate |
$2,453.89 |
| Rate for Payer: Aetna Commercial |
$673.75
|
| Rate for Payer: Anthem Medicaid |
$300.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,752.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$682.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,453.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,366.25
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$726.25
|
| Rate for Payer: First Health Commercial |
$831.25
|
| Rate for Payer: Humana Commercial |
$743.75
|
| Rate for Payer: Humana KY Medicaid |
$300.91
|
| Rate for Payer: Humana Medicare Advantage |
$1,752.78
|
| Rate for Payer: Kentucky WC Medicaid |
$303.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$717.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,103.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$306.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$770.00
|
| Rate for Payer: Ohio Health Group HMO |
$656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$761.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.75
|
| Rate for Payer: PHCS Commercial |
$840.00
|
| Rate for Payer: United Healthcare All Payer |
$770.00
|
|
|
EGD CAUTERY TUMOR POLYP(P
|
Professional
|
Both
|
$875.00
|
|
|
Service Code
|
HCPCS 43250
|
| Hospital Charge Code |
761P1746
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.39 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$286.74
|
| Rate for Payer: Ambetter Exchange |
$159.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$161.21
|
| Rate for Payer: Anthem Medicaid |
$227.73
|
| Rate for Payer: Buckeye Individual/Medicaid |
$159.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$159.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$191.27
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$261.98
|
| Rate for Payer: Healthspan PPO |
$241.81
|
| Rate for Payer: Humana Medicaid |
$227.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$159.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$232.28
|
| Rate for Payer: Molina Healthcare Passport |
$227.73
|
| Rate for Payer: Multiplan PHCS |
$525.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$207.21
|
| Rate for Payer: UHCCP Medicaid |
$169.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$230.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$159.39
|
|
|
EGD CONTROL BLEEDING ANY
|
Professional
|
Both
|
$1,015.00
|
|
|
Service Code
|
HCPCS 43255
|
| Hospital Charge Code |
76101749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$186.65 |
| Max. Negotiated Rate |
$609.00 |
| Rate for Payer: Aetna Commercial |
$432.67
|
| Rate for Payer: Ambetter Exchange |
$186.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$196.25
|
| Rate for Payer: Anthem Medicaid |
$289.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$186.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$186.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$223.98
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$388.52
|
| Rate for Payer: Healthspan PPO |
$364.88
|
| Rate for Payer: Humana Medicaid |
$289.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$186.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$295.14
|
| Rate for Payer: Molina Healthcare Passport |
$289.35
|
| Rate for Payer: Multiplan PHCS |
$609.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$242.65
|
| Rate for Payer: UHCCP Medicaid |
$206.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$292.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$186.65
|
|
|
EGD CONTROL BLEEDING ANY
|
Facility
|
OP
|
$1,015.00
|
|
|
Service Code
|
HCPCS 43255
|
| Hospital Charge Code |
76101749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$349.06 |
| Max. Negotiated Rate |
$2,453.89 |
| Rate for Payer: Aetna Commercial |
$781.55
|
| Rate for Payer: Anthem Medicaid |
$349.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,752.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$791.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,453.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,366.25
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$842.45
|
| Rate for Payer: First Health Commercial |
$964.25
|
| Rate for Payer: Humana Commercial |
$862.75
|
| Rate for Payer: Humana KY Medicaid |
$349.06
|
| Rate for Payer: Humana Medicare Advantage |
$1,752.78
|
| Rate for Payer: Kentucky WC Medicaid |
$352.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$832.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$749.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,103.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$356.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$893.20
|
| Rate for Payer: Ohio Health Group HMO |
$761.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$812.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$700.35
|
| Rate for Payer: PHCS Commercial |
$974.40
|
| Rate for Payer: United Healthcare All Payer |
$893.20
|
|
|
EGD CONTROL BLEEDING ANY
|
Facility
|
IP
|
$1,015.00
|
|
|
Service Code
|
HCPCS 43255
|
| Hospital Charge Code |
76101749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$304.50 |
| Max. Negotiated Rate |
$974.40 |
| Rate for Payer: Aetna Commercial |
$781.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$791.70
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$842.45
|
| Rate for Payer: First Health Commercial |
$964.25
|
| Rate for Payer: Humana Commercial |
$862.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$832.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$749.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$304.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$893.20
|
| Rate for Payer: Ohio Health Group HMO |
$761.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$812.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$883.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$700.35
|
| Rate for Payer: PHCS Commercial |
$974.40
|
| Rate for Payer: United Healthcare All Payer |
$893.20
|
|
|
EGD CONTROL BLEEDING ANY(P
|
Professional
|
Both
|
$1,015.00
|
|
|
Service Code
|
HCPCS 43255
|
| Hospital Charge Code |
761P1749
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$186.65 |
| Max. Negotiated Rate |
$609.00 |
| Rate for Payer: Aetna Commercial |
$432.67
|
| Rate for Payer: Ambetter Exchange |
$186.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$196.25
|
| Rate for Payer: Anthem Medicaid |
$289.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$186.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$186.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$223.98
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$388.52
|
| Rate for Payer: Healthspan PPO |
$364.88
|
| Rate for Payer: Humana Medicaid |
$289.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$186.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$295.14
|
| Rate for Payer: Molina Healthcare Passport |
$289.35
|
| Rate for Payer: Multiplan PHCS |
$609.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$242.65
|
| Rate for Payer: UHCCP Medicaid |
$206.06
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$292.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$186.65
|
|
|
EGD DIAGNOSTIC BRUSH WASH
|
Facility
|
IP
|
$3,321.00
|
|
|
Service Code
|
HCPCS 43235
|
| Hospital Charge Code |
76101736
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$996.30 |
| Max. Negotiated Rate |
$3,188.16 |
| Rate for Payer: Aetna Commercial |
$2,557.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,590.38
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cigna Commercial |
$2,756.43
|
| Rate for Payer: First Health Commercial |
$3,154.95
|
| Rate for Payer: Humana Commercial |
$2,822.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,723.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,922.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,656.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,889.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,291.49
|
| Rate for Payer: PHCS Commercial |
$3,188.16
|
| Rate for Payer: United Healthcare All Payer |
$2,922.48
|
|
|
EGD DIAGNOSTIC BRUSH WASH
|
Facility
|
OP
|
$3,321.00
|
|
|
Service Code
|
HCPCS 43235
|
| Hospital Charge Code |
76101736
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$866.29 |
| Max. Negotiated Rate |
$3,188.16 |
| Rate for Payer: Aetna Commercial |
$2,557.17
|
| Rate for Payer: Anthem Medicaid |
$1,142.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$866.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,590.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,212.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,169.49
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cash Price |
$1,660.50
|
| Rate for Payer: Cigna Commercial |
$2,756.43
|
| Rate for Payer: First Health Commercial |
$3,154.95
|
| Rate for Payer: Humana Commercial |
$2,822.85
|
| Rate for Payer: Humana KY Medicaid |
$1,142.09
|
| Rate for Payer: Humana Medicare Advantage |
$866.29
|
| Rate for Payer: Kentucky WC Medicaid |
$1,153.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,723.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,165.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,922.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,656.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,889.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,291.49
|
| Rate for Payer: PHCS Commercial |
$3,188.16
|
| Rate for Payer: United Healthcare All Payer |
$2,922.48
|
|
