|
EQUINOX REV HUM LNR CN 38M+2.5
|
Facility
|
OP
|
$5,641.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,692.38 |
| Max. Negotiated Rate |
$5,415.60 |
| Rate for Payer: Aetna Commercial |
$4,343.76
|
| Rate for Payer: Anthem Medicaid |
$1,940.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,400.18
|
| Rate for Payer: Cash Price |
$2,820.62
|
| Rate for Payer: Cigna Commercial |
$4,682.24
|
| Rate for Payer: First Health Commercial |
$5,359.19
|
| Rate for Payer: Humana Commercial |
$4,795.06
|
| Rate for Payer: Humana KY Medicaid |
$1,940.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1,959.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,625.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,163.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,692.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,978.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,964.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,230.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,513.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,907.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,892.46
|
| Rate for Payer: PHCS Commercial |
$5,415.60
|
| Rate for Payer: United Healthcare All Payer |
$4,964.30
|
|
|
EQUINOX REV HUM LNR CN 38M+2.5
|
Facility
|
IP
|
$5,641.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,692.38 |
| Max. Negotiated Rate |
$5,415.60 |
| Rate for Payer: Aetna Commercial |
$4,343.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,400.18
|
| Rate for Payer: Cash Price |
$2,820.62
|
| Rate for Payer: Cigna Commercial |
$4,682.24
|
| Rate for Payer: First Health Commercial |
$5,359.19
|
| Rate for Payer: Humana Commercial |
$4,795.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,625.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,163.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,692.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,964.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,230.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,513.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,907.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,892.46
|
| Rate for Payer: PHCS Commercial |
$5,415.60
|
| Rate for Payer: United Healthcare All Payer |
$4,964.30
|
|
|
EQUINOX REV HUM LNR CN 42M+2.5
|
Facility
|
OP
|
$5,641.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,692.38 |
| Max. Negotiated Rate |
$5,415.60 |
| Rate for Payer: Aetna Commercial |
$4,343.76
|
| Rate for Payer: Anthem Medicaid |
$1,940.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,400.18
|
| Rate for Payer: Cash Price |
$2,820.62
|
| Rate for Payer: Cigna Commercial |
$4,682.24
|
| Rate for Payer: First Health Commercial |
$5,359.19
|
| Rate for Payer: Humana Commercial |
$4,795.06
|
| Rate for Payer: Humana KY Medicaid |
$1,940.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1,959.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,625.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,163.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,692.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,978.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,964.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,230.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,513.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,907.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,892.46
|
| Rate for Payer: PHCS Commercial |
$5,415.60
|
| Rate for Payer: United Healthcare All Payer |
$4,964.30
|
|
|
EQUINOX REV HUM LNR CN 42M+2.5
|
Facility
|
IP
|
$5,641.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,692.38 |
| Max. Negotiated Rate |
$5,415.60 |
| Rate for Payer: Aetna Commercial |
$4,343.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,400.18
|
| Rate for Payer: Cash Price |
$2,820.62
|
| Rate for Payer: Cigna Commercial |
$4,682.24
|
| Rate for Payer: First Health Commercial |
$5,359.19
|
| Rate for Payer: Humana Commercial |
$4,795.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,625.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,163.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,692.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,964.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,230.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,513.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,907.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,892.46
|
| Rate for Payer: PHCS Commercial |
$5,415.60
|
| Rate for Payer: United Healthcare All Payer |
$4,964.30
|
|
|
EQUINOX REV HUM LNR CN 46M+2.5
|
Facility
|
IP
|
$5,641.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,692.38 |
| Max. Negotiated Rate |
$5,415.60 |
| Rate for Payer: Aetna Commercial |
$4,343.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,400.18
|
| Rate for Payer: Cash Price |
$2,820.62
|
| Rate for Payer: Cigna Commercial |
$4,682.24
|
| Rate for Payer: First Health Commercial |
$5,359.19
|
| Rate for Payer: Humana Commercial |
$4,795.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,625.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,163.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,692.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,964.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,230.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,513.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,907.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,892.46
|
| Rate for Payer: PHCS Commercial |
$5,415.60
|
| Rate for Payer: United Healthcare All Payer |
$4,964.30
|
|
|
EQUINOX REV HUM LNR CN 46M+2.5
|
Facility
|
OP
|
$5,641.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,692.38 |
| Max. Negotiated Rate |
$5,415.60 |
| Rate for Payer: Aetna Commercial |
$4,343.76
|
| Rate for Payer: Anthem Medicaid |
$1,940.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,400.18
|
| Rate for Payer: Cash Price |
$2,820.62
|
| Rate for Payer: Cigna Commercial |
$4,682.24
|
| Rate for Payer: First Health Commercial |
$5,359.19
|
| Rate for Payer: Humana Commercial |
$4,795.06
|
| Rate for Payer: Humana KY Medicaid |
$1,940.03
|
| Rate for Payer: Kentucky WC Medicaid |
$1,959.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,625.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,163.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,692.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,978.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,964.30
|
| Rate for Payer: Ohio Health Group HMO |
$4,230.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,513.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,907.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,892.46
|
| Rate for Payer: PHCS Commercial |
$5,415.60
|
| Rate for Payer: United Healthcare All Payer |
$4,964.30
|
|
|
ERASE IT KIT
|
Facility
|
OP
|
$190.00
|
|
| Hospital Charge Code |
22200134
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Anthem Medicaid |
$65.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.20
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: First Health Commercial |
$180.50
|
| Rate for Payer: Humana Commercial |
$161.50
|
| Rate for Payer: Humana KY Medicaid |
$65.34
|
| Rate for Payer: Kentucky WC Medicaid |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.20
|
| Rate for Payer: Ohio Health Group HMO |
$142.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.10
|
| Rate for Payer: PHCS Commercial |
$182.40
|
| Rate for Payer: United Healthcare All Payer |
$167.20
|
|
|
ERASE IT KIT
|
Facility
|
IP
|
$190.00
|
|
| Hospital Charge Code |
22200134
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$57.00 |
| Max. Negotiated Rate |
$182.40 |
| Rate for Payer: Aetna Commercial |
$146.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.20
|
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Cigna Commercial |
$157.70
|
| Rate for Payer: First Health Commercial |
$180.50
|
| Rate for Payer: Humana Commercial |
$161.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$155.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$167.20
|
| Rate for Payer: Ohio Health Group HMO |
$142.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$165.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.10
|
| Rate for Payer: PHCS Commercial |
$182.40
|
| Rate for Payer: United Healthcare All Payer |
$167.20
|
|
|
ERASE IT KIT
|
Professional
|
Both
|
$190.00
|
|
| Hospital Charge Code |
22200134
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$66.50 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Cash Price |
$95.00
|
| Rate for Payer: Multiplan PHCS |
$114.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$133.00
|
| Rate for Payer: UHCCP Medicaid |
$66.50
|
|
|
ERAVACYCLINE 1MG (100MG SDV)
|
Facility
|
OP
|
$635.85
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
25004226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.75 |
| Max. Negotiated Rate |
$610.42 |
| Rate for Payer: Aetna Commercial |
$489.60
|
| Rate for Payer: Anthem Medicaid |
$218.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$495.96
|
| Rate for Payer: Cash Price |
$317.92
|
| Rate for Payer: Cigna Commercial |
$527.76
|
| Rate for Payer: First Health Commercial |
$604.06
|
| Rate for Payer: Humana Commercial |
$540.47
|
| Rate for Payer: Humana KY Medicaid |
$218.67
|
| Rate for Payer: Kentucky WC Medicaid |
$220.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$521.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$469.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$223.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$559.55
|
| Rate for Payer: Ohio Health Group HMO |
$476.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.74
|
| Rate for Payer: PHCS Commercial |
$610.42
|
| Rate for Payer: United Healthcare All Payer |
$559.55
|
|
|
ERAVACYCLINE 1MG (100MG SDV)
|
Facility
|
IP
|
$635.85
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
25004226
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.75 |
| Max. Negotiated Rate |
$610.42 |
| Rate for Payer: Aetna Commercial |
$489.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$495.96
|
| Rate for Payer: Cash Price |
$317.92
|
| Rate for Payer: Cigna Commercial |
$527.76
|
| Rate for Payer: First Health Commercial |
$604.06
|
| Rate for Payer: Humana Commercial |
$540.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$521.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$469.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$559.55
|
| Rate for Payer: Ohio Health Group HMO |
$476.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$508.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$553.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$438.74
|
| Rate for Payer: PHCS Commercial |
$610.42
|
| Rate for Payer: United Healthcare All Payer |
$559.55
|
|
|
ERAVACYCLINE 1mg (50mg SDV)
|
Facility
|
IP
|
$267.05
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
25003945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.11 |
| Max. Negotiated Rate |
$256.37 |
| Rate for Payer: Aetna Commercial |
$205.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$208.30
|
| Rate for Payer: Cash Price |
$133.52
|
| Rate for Payer: Cigna Commercial |
$221.65
|
| Rate for Payer: First Health Commercial |
$253.70
|
| Rate for Payer: Humana Commercial |
$226.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$235.00
|
| Rate for Payer: Ohio Health Group HMO |
$200.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.26
|
| Rate for Payer: PHCS Commercial |
$256.37
|
| Rate for Payer: United Healthcare All Payer |
$235.00
|
|
|
ERAVACYCLINE 1mg (50mg SDV)
|
Facility
|
OP
|
$267.05
|
|
|
Service Code
|
HCPCS J0122
|
| Hospital Charge Code |
25003945
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$80.11 |
| Max. Negotiated Rate |
$256.37 |
| Rate for Payer: Aetna Commercial |
$205.63
|
| Rate for Payer: Anthem Medicaid |
$91.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$208.30
|
| Rate for Payer: Cash Price |
$133.52
|
| Rate for Payer: Cigna Commercial |
$221.65
|
| Rate for Payer: First Health Commercial |
$253.70
|
| Rate for Payer: Humana Commercial |
$226.99
|
| Rate for Payer: Humana KY Medicaid |
$91.84
|
| Rate for Payer: Kentucky WC Medicaid |
$92.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$197.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$235.00
|
| Rate for Payer: Ohio Health Group HMO |
$200.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$213.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$184.26
|
| Rate for Payer: PHCS Commercial |
$256.37
|
| Rate for Payer: United Healthcare All Payer |
$235.00
|
|
|
ERBE HYBRID KNIFE
|
Facility
|
IP
|
$4,096.25
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,228.88 |
| Max. Negotiated Rate |
$3,932.40 |
| Rate for Payer: Aetna Commercial |
$3,154.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,195.07
|
| Rate for Payer: Cash Price |
$2,048.12
|
| Rate for Payer: Cigna Commercial |
$3,399.89
|
| Rate for Payer: First Health Commercial |
$3,891.44
|
| Rate for Payer: Humana Commercial |
$3,481.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,358.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,023.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,228.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,604.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,072.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,277.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,563.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,826.41
|
| Rate for Payer: PHCS Commercial |
$3,932.40
|
| Rate for Payer: United Healthcare All Payer |
$3,604.70
|
|
|
ERBE HYBRID KNIFE
|
Facility
|
OP
|
$4,096.25
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,228.88 |
| Max. Negotiated Rate |
$3,932.40 |
| Rate for Payer: Aetna Commercial |
$3,154.11
|
| Rate for Payer: Anthem Medicaid |
$1,408.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,195.07
|
| Rate for Payer: Cash Price |
$2,048.12
|
| Rate for Payer: Cigna Commercial |
$3,399.89
|
| Rate for Payer: First Health Commercial |
$3,891.44
|
| Rate for Payer: Humana Commercial |
$3,481.81
|
| Rate for Payer: Humana KY Medicaid |
$1,408.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,423.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,358.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,023.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,228.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,436.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,604.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,072.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,277.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,563.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,826.41
|
| Rate for Payer: PHCS Commercial |
$3,932.40
|
| Rate for Payer: United Healthcare All Payer |
$3,604.70
|
|
|
ERBITUX 200MG/100ML VIAL
|
Facility
|
IP
|
$8,852.16
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
25003883
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,655.65 |
| Max. Negotiated Rate |
$8,498.07 |
| Rate for Payer: Aetna Commercial |
$6,816.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,904.68
|
| Rate for Payer: Cash Price |
$4,426.08
|
| Rate for Payer: Cigna Commercial |
$7,347.29
|
| Rate for Payer: First Health Commercial |
$8,409.55
|
| Rate for Payer: Humana Commercial |
$7,524.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,258.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,532.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,655.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,789.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,639.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,081.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,701.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,107.99
|
| Rate for Payer: PHCS Commercial |
$8,498.07
|
| Rate for Payer: United Healthcare All Payer |
$7,789.90
|
|
|
ERBITUX 200MG/100ML VIAL
|
Facility
|
OP
|
$8,852.16
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
25003883
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.47 |
| Max. Negotiated Rate |
$8,498.07 |
| Rate for Payer: Aetna Commercial |
$6,816.16
|
| Rate for Payer: Anthem Medicaid |
$3,044.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,904.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$109.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.93
|
| Rate for Payer: Cash Price |
$4,426.08
|
| Rate for Payer: Cash Price |
$4,426.08
|
| Rate for Payer: Cigna Commercial |
$7,347.29
|
| Rate for Payer: First Health Commercial |
$8,409.55
|
| Rate for Payer: Humana Commercial |
$7,524.34
|
| Rate for Payer: Humana KY Medicaid |
$3,044.26
|
| Rate for Payer: Humana Medicare Advantage |
$78.47
|
| Rate for Payer: Kentucky WC Medicaid |
$3,075.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,258.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,532.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,105.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,789.90
|
| Rate for Payer: Ohio Health Group HMO |
$6,639.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,081.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,701.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,107.99
|
| Rate for Payer: PHCS Commercial |
$8,498.07
|
| Rate for Payer: United Healthcare All Payer |
$7,789.90
|
|
|
ERBITUX DS 10 MG/ 5 ML
|
Facility
|
OP
|
$4,426.11
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
25002582
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$78.47 |
| Max. Negotiated Rate |
$4,249.07 |
| Rate for Payer: Aetna Commercial |
$3,408.10
|
| Rate for Payer: Anthem Medicaid |
$1,522.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,452.37
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$109.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$105.93
|
| Rate for Payer: Cash Price |
$2,213.05
|
| Rate for Payer: Cash Price |
$2,213.05
|
| Rate for Payer: Cigna Commercial |
$3,673.67
|
| Rate for Payer: First Health Commercial |
$4,204.80
|
| Rate for Payer: Humana Commercial |
$3,762.19
|
| Rate for Payer: Humana KY Medicaid |
$1,522.14
|
| Rate for Payer: Humana Medicare Advantage |
$78.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1,537.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,629.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,266.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,552.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,894.98
|
| Rate for Payer: Ohio Health Group HMO |
$3,319.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,850.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,054.02
|
| Rate for Payer: PHCS Commercial |
$4,249.07
|
| Rate for Payer: United Healthcare All Payer |
$3,894.98
|
|
|
ERBITUX DS 10 MG/ 5 ML
|
Facility
|
IP
|
$4,426.11
|
|
|
Service Code
|
HCPCS J9055
|
| Hospital Charge Code |
25002582
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,327.83 |
| Max. Negotiated Rate |
$4,249.07 |
| Rate for Payer: Aetna Commercial |
$3,408.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,452.37
|
| Rate for Payer: Cash Price |
$2,213.05
|
| Rate for Payer: Cigna Commercial |
$3,673.67
|
| Rate for Payer: First Health Commercial |
$4,204.80
|
| Rate for Payer: Humana Commercial |
$3,762.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,629.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,266.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,327.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,894.98
|
| Rate for Payer: Ohio Health Group HMO |
$3,319.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,850.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,054.02
|
| Rate for Payer: PHCS Commercial |
$4,249.07
|
| Rate for Payer: United Healthcare All Payer |
$3,894.98
|
|
|
ERCP DUCT STENT PLACEMENT
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 43274
|
| Hospital Charge Code |
76101759
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
ERCP DUCT STENT PLACEMENT
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 43274
|
| Hospital Charge Code |
76101759
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$343.90 |
| Max. Negotiated Rate |
$7,700.39 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,500.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,700.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,425.38
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$5,500.28
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,600.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$870.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$690.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
ERCP DUCT STENT PLACEMENT
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 43274
|
| Hospital Charge Code |
76101759
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$799.74 |
| Rate for Payer: Ambetter Exchange |
$429.71
|
| Rate for Payer: Anthem Medicaid |
$388.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$429.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$429.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$515.65
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$799.74
|
| Rate for Payer: Healthspan PPO |
$663.74
|
| Rate for Payer: Humana Medicaid |
$388.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$627.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$429.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$429.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.37
|
| Rate for Payer: Molina Healthcare Passport |
$388.60
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$558.62
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$392.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$429.71
|
|
|
ERCP DUCT STENT PLACEMENT(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 43274
|
| Hospital Charge Code |
761P1759
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$350.00 |
| Max. Negotiated Rate |
$799.74 |
| Rate for Payer: Ambetter Exchange |
$429.71
|
| Rate for Payer: Anthem Medicaid |
$388.60
|
| Rate for Payer: Buckeye Individual/Medicaid |
$429.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$429.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$515.65
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$799.74
|
| Rate for Payer: Healthspan PPO |
$663.74
|
| Rate for Payer: Humana Medicaid |
$388.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$627.49
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$429.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$429.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.37
|
| Rate for Payer: Molina Healthcare Passport |
$388.60
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$558.62
|
| Rate for Payer: UHCCP Medicaid |
$350.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$392.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$429.71
|
|
|
ERCP EA DUCT/AMPULLA DILATE
|
Facility
|
IP
|
$825.00
|
|
|
Service Code
|
HCPCS 43277
|
| Hospital Charge Code |
76101762
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$247.50 |
| Max. Negotiated Rate |
$792.00 |
| Rate for Payer: Aetna Commercial |
$635.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$643.50
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Cigna Commercial |
$684.75
|
| Rate for Payer: First Health Commercial |
$783.75
|
| Rate for Payer: Humana Commercial |
$701.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$676.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$608.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$247.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$726.00
|
| Rate for Payer: Ohio Health Group HMO |
$618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$660.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$717.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$569.25
|
| Rate for Payer: PHCS Commercial |
$792.00
|
| Rate for Payer: United Healthcare All Payer |
$726.00
|
|
|
ERCP EA DUCT/AMPULLA DILATE
|
Professional
|
Both
|
$825.00
|
|
|
Service Code
|
HCPCS 43277
|
| Hospital Charge Code |
76101762
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$288.75 |
| Max. Negotiated Rate |
$663.34 |
| Rate for Payer: Ambetter Exchange |
$351.62
|
| Rate for Payer: Anthem Medicaid |
$322.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$351.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$351.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$421.94
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Cash Price |
$412.50
|
| Rate for Payer: Cigna Commercial |
$663.34
|
| Rate for Payer: Healthspan PPO |
$550.46
|
| Rate for Payer: Humana Medicaid |
$322.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$520.41
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$351.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$328.72
|
| Rate for Payer: Molina Healthcare Passport |
$322.27
|
| Rate for Payer: Multiplan PHCS |
$495.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$457.11
|
| Rate for Payer: UHCCP Medicaid |
$288.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$325.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$351.62
|
|
