|
ELATION PUL BALL DIL 2CM 12-13
|
Facility
|
OP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem Medicaid |
$1,042.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Humana KY Medicaid |
$1,042.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,053.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,063.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 2CM 8-9-1
|
Facility
|
IP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 2CM 8-9-1
|
Facility
|
OP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem Medicaid |
$1,042.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Humana KY Medicaid |
$1,042.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,053.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,063.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 10-11
|
Facility
|
OP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem Medicaid |
$1,042.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Humana KY Medicaid |
$1,042.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,053.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,063.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 10-11
|
Facility
|
IP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 12-13
|
Facility
|
OP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem Medicaid |
$1,042.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Humana KY Medicaid |
$1,042.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,053.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,063.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 12-13
|
Facility
|
IP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 6-7-8
|
Facility
|
OP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem Medicaid |
$1,042.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Humana KY Medicaid |
$1,042.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,053.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,063.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 6-7-8
|
Facility
|
IP
|
$3,031.25
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$909.38 |
| Max. Negotiated Rate |
$2,910.00 |
| Rate for Payer: Aetna Commercial |
$2,334.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,364.38
|
| Rate for Payer: Cash Price |
$1,515.62
|
| Rate for Payer: Cigna Commercial |
$2,515.94
|
| Rate for Payer: First Health Commercial |
$2,879.69
|
| Rate for Payer: Humana Commercial |
$2,576.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,485.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,237.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$909.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,667.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,273.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,425.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,637.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,091.56
|
| Rate for Payer: PHCS Commercial |
$2,910.00
|
| Rate for Payer: United Healthcare All Payer |
$2,667.50
|
|
|
ELATION PUL BALL DIL 3CM 8-9-1
|
Facility
|
OP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem Medicaid |
$708.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Humana KY Medicaid |
$708.43
|
| Rate for Payer: Kentucky WC Medicaid |
$715.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
ELATION PUL BALL DIL 3CM 8-9-1
|
Facility
|
IP
|
$2,060.00
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$618.00 |
| Max. Negotiated Rate |
$1,977.60 |
| Rate for Payer: Aetna Commercial |
$1,586.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.80
|
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Cigna Commercial |
$1,709.80
|
| Rate for Payer: First Health Commercial |
$1,957.00
|
| Rate for Payer: Humana Commercial |
$1,751.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.40
|
| Rate for Payer: PHCS Commercial |
$1,977.60
|
| Rate for Payer: United Healthcare All Payer |
$1,812.80
|
|
|
ELATION PULM BALLN DIL 2CM 6-7
|
Facility
|
IP
|
$3,068.75
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$920.62 |
| Max. Negotiated Rate |
$2,946.00 |
| Rate for Payer: Aetna Commercial |
$2,362.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,393.62
|
| Rate for Payer: Cash Price |
$1,534.38
|
| Rate for Payer: Cigna Commercial |
$2,547.06
|
| Rate for Payer: First Health Commercial |
$2,915.31
|
| Rate for Payer: Humana Commercial |
$2,608.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,516.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,264.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$920.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,700.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,301.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,455.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,669.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,117.44
|
| Rate for Payer: PHCS Commercial |
$2,946.00
|
| Rate for Payer: United Healthcare All Payer |
$2,700.50
|
|
|
ELATION PULM BALLN DIL 2CM 6-7
|
Facility
|
OP
|
$3,068.75
|
|
|
Service Code
|
HCPCS C1726
|
| Hospital Charge Code |
27000010
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$920.62 |
| Max. Negotiated Rate |
$2,946.00 |
| Rate for Payer: Aetna Commercial |
$2,362.94
|
| Rate for Payer: Anthem Medicaid |
$1,055.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,393.62
|
| Rate for Payer: Cash Price |
$1,534.38
|
| Rate for Payer: Cigna Commercial |
$2,547.06
|
| Rate for Payer: First Health Commercial |
$2,915.31
|
| Rate for Payer: Humana Commercial |
$2,608.44
|
| Rate for Payer: Humana KY Medicaid |
$1,055.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,066.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,516.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,264.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$920.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,076.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,700.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,301.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,455.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,669.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,117.44
|
| Rate for Payer: PHCS Commercial |
$2,946.00
|
| Rate for Payer: United Healthcare All Payer |
$2,700.50
|
|
|
ELAVIL (AMITRIPTYLIN 10MG/1TAB
|
Facility
|
OP
|
$4.27
|
|
|
Service Code
|
NDC 16729017101
|
| Hospital Charge Code |
25000605
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
ELAVIL (AMITRIPTYLIN 10MG/1TAB
|
Facility
|
IP
|
$4.27
|
|
|
Service Code
|
NDC 16729017101
|
| Hospital Charge Code |
25000605
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$4.10 |
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.06
|
| Rate for Payer: Humana Commercial |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.76
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.95
|
| Rate for Payer: PHCS Commercial |
$4.10
|
| Rate for Payer: United Healthcare All Payer |
$3.76
|
|
|
ELAVIL (AMITRIPTYLIN 25MG/1TAB
|
Facility
|
IP
|
$4.63
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
25000606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
ELAVIL (AMITRIPTYLIN 25MG/1TAB
|
Facility
|
OP
|
$4.63
|
|
|
Service Code
|
NDC 60687043301
|
| Hospital Charge Code |
25000606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.57
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.61
|
| Rate for Payer: Cash Price |
$2.32
|
| Rate for Payer: Cigna Commercial |
$3.84
|
| Rate for Payer: First Health Commercial |
$4.40
|
| Rate for Payer: Humana Commercial |
$3.94
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
ELAVIL (AMITRIPTYLIN 50MG/1TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 60687044401
|
| Hospital Charge Code |
25000607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
ELAVIL (AMITRIPTYLIN 50MG/1TAB
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 60687044401
|
| Hospital Charge Code |
25000607
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
ELBOW LT 2V
|
Facility
|
IP
|
$404.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
32000079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$121.20 |
| Max. Negotiated Rate |
$387.84 |
| Rate for Payer: Aetna Commercial |
$311.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$315.12
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cigna Commercial |
$335.32
|
| Rate for Payer: First Health Commercial |
$383.80
|
| Rate for Payer: Humana Commercial |
$343.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$331.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$298.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$355.52
|
| Rate for Payer: Ohio Health Group HMO |
$303.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$323.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$351.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.76
|
| Rate for Payer: PHCS Commercial |
$387.84
|
| Rate for Payer: United Healthcare All Payer |
$355.52
|
|
|
ELBOW LT 2V
|
Professional
|
Both
|
$404.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
32000079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$242.40 |
| Rate for Payer: Aetna Commercial |
$40.23
|
| Rate for Payer: Ambetter Exchange |
$26.47
|
| Rate for Payer: Anthem Medicaid |
$20.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.76
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cigna Commercial |
$40.25
|
| Rate for Payer: Healthspan PPO |
$37.70
|
| Rate for Payer: Humana Medicaid |
$20.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$9.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.07
|
| Rate for Payer: Molina Healthcare Passport |
$20.66
|
| Rate for Payer: Multiplan PHCS |
$242.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.41
|
| Rate for Payer: UHCCP Medicaid |
$141.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.47
|
|
|
ELBOW LT 2V
|
Facility
|
OP
|
$404.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
32000079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$387.84 |
| Rate for Payer: Aetna Commercial |
$311.08
|
| Rate for Payer: Anthem Medicaid |
$138.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$315.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cash Price |
$202.00
|
| Rate for Payer: Cigna Commercial |
$335.32
|
| Rate for Payer: First Health Commercial |
$383.80
|
| Rate for Payer: Humana Commercial |
$343.40
|
| Rate for Payer: Humana KY Medicaid |
$138.94
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$140.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$331.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$298.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$141.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$355.52
|
| Rate for Payer: Ohio Health Group HMO |
$303.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$323.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$351.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.76
|
| Rate for Payer: PHCS Commercial |
$387.84
|
| Rate for Payer: United Healthcare All Payer |
$355.52
|
|
|
ELBOW LT 2V(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
320P0079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$40.25 |
| Rate for Payer: Aetna Commercial |
$40.23
|
| Rate for Payer: Ambetter Exchange |
$26.47
|
| Rate for Payer: Anthem Medicaid |
$20.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.76
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$40.25
|
| Rate for Payer: Healthspan PPO |
$37.70
|
| Rate for Payer: Humana Medicaid |
$20.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$9.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.07
|
| Rate for Payer: Molina Healthcare Passport |
$20.66
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.41
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.47
|
|
|
ELBOW LT 2V(T
|
Facility
|
IP
|
$354.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
320T0079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$106.20 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$106.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
|
ELBOW LT 2V(T
|
Facility
|
OP
|
$354.00
|
|
|
Service Code
|
HCPCS 73070
|
| Hospital Charge Code |
320T0079
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$339.84 |
| Rate for Payer: Aetna Commercial |
$272.58
|
| Rate for Payer: Anthem Medicaid |
$121.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$276.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cash Price |
$177.00
|
| Rate for Payer: Cigna Commercial |
$293.82
|
| Rate for Payer: First Health Commercial |
$336.30
|
| Rate for Payer: Humana Commercial |
$300.90
|
| Rate for Payer: Humana KY Medicaid |
$121.74
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$122.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$290.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$261.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$124.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$311.52
|
| Rate for Payer: Ohio Health Group HMO |
$265.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$283.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$244.26
|
| Rate for Payer: PHCS Commercial |
$339.84
|
| Rate for Payer: United Healthcare All Payer |
$311.52
|
|
