|
ALUMINA V40 FEM HEAD -5 36MM
|
Facility
|
OP
|
$8,932.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.16 |
| Max. Negotiated Rate |
$8,574.72 |
| Rate for Payer: Aetna Commercial |
$6,877.64
|
| Rate for Payer: Anthem Medicaid |
$3,071.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.96
|
| Rate for Payer: Cash Price |
$4,466.00
|
| Rate for Payer: Cigna Commercial |
$7,413.56
|
| Rate for Payer: First Health Commercial |
$8,485.40
|
| Rate for Payer: Humana Commercial |
$7,592.20
|
| Rate for Payer: Humana KY Medicaid |
$3,071.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3,102.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,324.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,133.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,860.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,699.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,786.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,768.92
|
| Rate for Payer: PHCS Commercial |
$8,574.72
|
| Rate for Payer: United Healthcare All Payer |
$7,860.16
|
|
|
ALUMINA V40 FEM HEAD -5 36MM
|
Facility
|
IP
|
$8,932.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,161.16 |
| Max. Negotiated Rate |
$8,574.72 |
| Rate for Payer: Aetna Commercial |
$6,877.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,966.96
|
| Rate for Payer: Cash Price |
$4,466.00
|
| Rate for Payer: Cigna Commercial |
$7,413.56
|
| Rate for Payer: First Health Commercial |
$8,485.40
|
| Rate for Payer: Humana Commercial |
$7,592.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,324.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,591.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,679.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,860.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,699.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,786.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,161.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,768.92
|
| Rate for Payer: PHCS Commercial |
$8,574.72
|
| Rate for Payer: United Healthcare All Payer |
$7,860.16
|
|
|
ALUM US 36MM HD 12/14 TPR +0 S
|
Facility
|
OP
|
$11,768.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,529.84 |
| Max. Negotiated Rate |
$11,297.28 |
| Rate for Payer: Aetna Commercial |
$9,061.36
|
| Rate for Payer: Anthem Medicaid |
$4,047.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,179.04
|
| Rate for Payer: Cash Price |
$5,884.00
|
| Rate for Payer: Cigna Commercial |
$9,767.44
|
| Rate for Payer: First Health Commercial |
$11,179.60
|
| Rate for Payer: Humana Commercial |
$10,002.80
|
| Rate for Payer: Humana KY Medicaid |
$4,047.02
|
| Rate for Payer: Kentucky WC Medicaid |
$4,088.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,649.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,684.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,530.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,128.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,355.84
|
| Rate for Payer: Ohio Health Group HMO |
$8,826.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,529.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,648.08
|
| Rate for Payer: PHCS Commercial |
$11,297.28
|
| Rate for Payer: United Healthcare All Payer |
$10,355.84
|
|
|
ALUM US 36MM HD 12/14 TPR +0 S
|
Facility
|
IP
|
$11,768.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,529.84 |
| Max. Negotiated Rate |
$11,297.28 |
| Rate for Payer: Aetna Commercial |
$9,061.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,179.04
|
| Rate for Payer: Cash Price |
$5,884.00
|
| Rate for Payer: Cigna Commercial |
$9,767.44
|
| Rate for Payer: First Health Commercial |
$11,179.60
|
| Rate for Payer: Humana Commercial |
$10,002.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,649.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,684.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,530.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,355.84
|
| Rate for Payer: Ohio Health Group HMO |
$8,826.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,353.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,529.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,648.08
|
| Rate for Payer: PHCS Commercial |
$11,297.28
|
| Rate for Payer: United Healthcare All Payer |
$10,355.84
|
|
|
ALUM US 36MM HD 12/14 TPR +4 M
|
Facility
|
IP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
ALUM US 36MM HD 12/14 TPR +4 M
|
Facility
|
OP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem Medicaid |
$3,960.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Humana KY Medicaid |
$3,960.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,000.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,039.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
ALUM US 36MM HD 12/14 TPR +8 L
|
Facility
|
OP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem Medicaid |
$3,960.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Humana KY Medicaid |
$3,960.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,000.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,039.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
ALUM US 36MM HD 12/14 TPR +8 L
|
Facility
|
IP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
ALYMSYS 10mg (100mg SDV)
|
Facility
|
IP
|
$3,916.37
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004320
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$509.13 |
| Max. Negotiated Rate |
$3,759.72 |
| Rate for Payer: Aetna Commercial |
$3,015.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,054.77
|
| Rate for Payer: Cash Price |
$1,958.18
|
| Rate for Payer: Cigna Commercial |
$3,250.59
|
| Rate for Payer: First Health Commercial |
$3,720.55
|
| Rate for Payer: Humana Commercial |
$3,328.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,211.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,890.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,174.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,446.41
|
| Rate for Payer: Ohio Health Group HMO |
$2,937.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,214.07
|
| Rate for Payer: PHCS Commercial |
$3,759.72
|
| Rate for Payer: United Healthcare All Payer |
$3,446.41
|
|
|
ALYMSYS 10mg (100mg SDV)
|
Facility
|
OP
|
$3,916.37
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004320
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.58 |
| Max. Negotiated Rate |
$3,759.72 |
| Rate for Payer: Aetna Commercial |
$3,015.60
|
| Rate for Payer: Anthem Medicaid |
$1,346.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,054.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$84.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$81.79
|
| Rate for Payer: Cash Price |
$1,958.18
|
| Rate for Payer: Cash Price |
$1,958.18
|
| Rate for Payer: Cigna Commercial |
$3,250.59
|
| Rate for Payer: First Health Commercial |
$3,720.55
|
| Rate for Payer: Humana Commercial |
$3,328.91
|
| Rate for Payer: Humana KY Medicaid |
$1,346.84
|
| Rate for Payer: Humana Medicare Advantage |
$60.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,360.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,211.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,890.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,373.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,446.41
|
| Rate for Payer: Ohio Health Group HMO |
$2,937.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$783.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$509.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,214.07
|
| Rate for Payer: PHCS Commercial |
$3,759.72
|
| Rate for Payer: United Healthcare All Payer |
$3,446.41
|
|
|
ALYMSYS 10mg (400mg SDV)
|
Facility
|
OP
|
$15,665.48
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.58 |
| Max. Negotiated Rate |
$15,038.86 |
| Rate for Payer: Aetna Commercial |
$12,062.42
|
| Rate for Payer: Anthem Medicaid |
$5,387.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$60.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,219.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$84.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$81.79
|
| Rate for Payer: Cash Price |
$7,832.74
|
| Rate for Payer: Cash Price |
$7,832.74
|
| Rate for Payer: Cigna Commercial |
$13,002.35
|
| Rate for Payer: First Health Commercial |
$14,882.21
|
| Rate for Payer: Humana Commercial |
$13,315.66
|
| Rate for Payer: Humana KY Medicaid |
$5,387.36
|
| Rate for Payer: Humana Medicare Advantage |
$60.58
|
| Rate for Payer: Kentucky WC Medicaid |
$5,442.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,845.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,561.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,495.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,785.62
|
| Rate for Payer: Ohio Health Group HMO |
$11,749.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,133.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,036.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,856.30
|
| Rate for Payer: PHCS Commercial |
$15,038.86
|
| Rate for Payer: United Healthcare All Payer |
$13,785.62
|
|
|
ALYMSYS 10mg (400mg SDV)
|
Facility
|
IP
|
$15,665.48
|
|
|
Service Code
|
HCPCS Q5126
|
| Hospital Charge Code |
25004321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,036.51 |
| Max. Negotiated Rate |
$15,038.86 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,845.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,561.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,699.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,785.62
|
| Rate for Payer: Ohio Health Group HMO |
$11,749.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,133.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,036.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,856.30
|
| Rate for Payer: PHCS Commercial |
$15,038.86
|
| Rate for Payer: United Healthcare All Payer |
$13,785.62
|
| Rate for Payer: Aetna Commercial |
$12,062.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,219.07
|
| Rate for Payer: Cash Price |
$7,832.74
|
| Rate for Payer: Cigna Commercial |
$13,002.35
|
| Rate for Payer: First Health Commercial |
$14,882.21
|
| Rate for Payer: Humana Commercial |
$13,315.66
|
|
|
ALYS SMPL SP/PN NPGT W/PRGRM
|
Facility
|
OP
|
$1,084.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
51000042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$83.71 |
| Max. Negotiated Rate |
$1,040.64 |
| Rate for Payer: Aetna Commercial |
$834.68
|
| Rate for Payer: Anthem Medicaid |
$372.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$83.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$845.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$117.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$113.01
|
| Rate for Payer: Cash Price |
$542.00
|
| Rate for Payer: Cash Price |
$542.00
|
| Rate for Payer: Cigna Commercial |
$899.72
|
| Rate for Payer: First Health Commercial |
$1,029.80
|
| Rate for Payer: Humana Commercial |
$921.40
|
| Rate for Payer: Humana KY Medicaid |
$372.79
|
| Rate for Payer: Humana Medicare Advantage |
$83.71
|
| Rate for Payer: Kentucky WC Medicaid |
$376.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$888.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$799.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$380.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$953.92
|
| Rate for Payer: Ohio Health Group HMO |
$813.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$216.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$140.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.04
|
| Rate for Payer: PHCS Commercial |
$1,040.64
|
| Rate for Payer: United Healthcare All Payer |
$953.92
|
|
|
ALYS SMPL SP/PN NPGT W/PRGRM
|
Professional
|
Both
|
$1,084.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
51000042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$1,084.00 |
| Rate for Payer: Aetna Commercial |
$63.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$20.25
|
| Rate for Payer: Anthem Medicaid |
$32.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,084.00
|
| Rate for Payer: Cash Price |
$542.00
|
| Rate for Payer: Cash Price |
$542.00
|
| Rate for Payer: Cigna Commercial |
$83.82
|
| Rate for Payer: Healthspan PPO |
$77.99
|
| Rate for Payer: Humana Medicaid |
$32.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.95
|
| Rate for Payer: Molina Healthcare Passport |
$32.30
|
| Rate for Payer: Multiplan PHCS |
$650.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$758.80
|
| Rate for Payer: UHCCP Medicaid |
$21.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.62
|
|
|
ALYS SMPL SP/PN NPGT W/PRGRM
|
Facility
|
IP
|
$1,084.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
51000042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$140.92 |
| Max. Negotiated Rate |
$1,040.64 |
| Rate for Payer: Aetna Commercial |
$834.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$845.52
|
| Rate for Payer: Cash Price |
$542.00
|
| Rate for Payer: Cigna Commercial |
$899.72
|
| Rate for Payer: First Health Commercial |
$1,029.80
|
| Rate for Payer: Humana Commercial |
$921.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$888.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$799.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$325.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$953.92
|
| Rate for Payer: Ohio Health Group HMO |
$813.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$216.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$140.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.04
|
| Rate for Payer: PHCS Commercial |
$1,040.64
|
| Rate for Payer: United Healthcare All Payer |
$953.92
|
|
|
ALYS SMPL SP/PN NPGT W/PRGR(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
510P0042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$20.25 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Aetna Commercial |
$63.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$20.25
|
| Rate for Payer: Anthem Medicaid |
$32.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$83.82
|
| Rate for Payer: Healthspan PPO |
$77.99
|
| Rate for Payer: Humana Medicaid |
$32.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$32.95
|
| Rate for Payer: Molina Healthcare Passport |
$32.30
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$21.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$32.62
|
|
|
ALYS SMPL SP/PN NPGT W/PRGR(T
|
Facility
|
OP
|
$934.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
510T0042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$83.71 |
| Max. Negotiated Rate |
$896.64 |
| Rate for Payer: Aetna Commercial |
$719.18
|
| Rate for Payer: Anthem Medicaid |
$321.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$83.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$728.52
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$117.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$113.01
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$775.22
|
| Rate for Payer: First Health Commercial |
$887.30
|
| Rate for Payer: Humana Commercial |
$793.90
|
| Rate for Payer: Humana KY Medicaid |
$321.20
|
| Rate for Payer: Humana Medicare Advantage |
$83.71
|
| Rate for Payer: Kentucky WC Medicaid |
$324.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$689.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$327.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.92
|
| Rate for Payer: Ohio Health Group HMO |
$700.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.54
|
| Rate for Payer: PHCS Commercial |
$896.64
|
| Rate for Payer: United Healthcare All Payer |
$821.92
|
|
|
ALYS SMPL SP/PN NPGT W/PRGR(T
|
Facility
|
IP
|
$934.00
|
|
|
Service Code
|
HCPCS 95971
|
| Hospital Charge Code |
510T0042
|
|
Hospital Revenue Code
|
920
|
| Min. Negotiated Rate |
$121.42 |
| Max. Negotiated Rate |
$896.64 |
| Rate for Payer: Aetna Commercial |
$719.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$728.52
|
| Rate for Payer: Cash Price |
$467.00
|
| Rate for Payer: Cigna Commercial |
$775.22
|
| Rate for Payer: First Health Commercial |
$887.30
|
| Rate for Payer: Humana Commercial |
$793.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$765.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$689.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$280.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$821.92
|
| Rate for Payer: Ohio Health Group HMO |
$700.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$186.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$121.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$289.54
|
| Rate for Payer: PHCS Commercial |
$896.64
|
| Rate for Payer: United Healthcare All Payer |
$821.92
|
|
|
AMANTADINE SYRUP 50 MG / 5 ML
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
NDC 121064616
|
| Hospital Charge Code |
25002521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
AMANTADINE SYRUP 50 MG / 5 ML
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
NDC 121064616
|
| Hospital Charge Code |
25002521
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
AMARYL (GLIMEPRIDE) 2MG/1TAB
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 50268035915
|
| Hospital Charge Code |
25000205
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
AMARYL (GLIMEPRIDE) 2MG/1TAB
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 50268035915
|
| Hospital Charge Code |
25000205
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
AMBIOTIC MEMBRANE 1.5*2CM
|
Facility
|
OP
|
$3,946.50
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.04 |
| Max. Negotiated Rate |
$3,788.64 |
| Rate for Payer: Aetna Commercial |
$3,038.80
|
| Rate for Payer: Anthem Medicaid |
$1,357.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,078.27
|
| Rate for Payer: Cash Price |
$1,973.25
|
| Rate for Payer: Cigna Commercial |
$3,275.60
|
| Rate for Payer: First Health Commercial |
$3,749.18
|
| Rate for Payer: Humana Commercial |
$3,354.52
|
| Rate for Payer: Humana KY Medicaid |
$1,357.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,371.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,236.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,912.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,183.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,384.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,472.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,959.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,223.42
|
| Rate for Payer: PHCS Commercial |
$3,788.64
|
| Rate for Payer: United Healthcare All Payer |
$3,472.92
|
|
|
AMBIOTIC MEMBRANE 1.5*2CM
|
Facility
|
IP
|
$3,946.50
|
|
|
Service Code
|
HCPCS V2790
|
| Hospital Charge Code |
27000055
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.04 |
| Max. Negotiated Rate |
$3,788.64 |
| Rate for Payer: Aetna Commercial |
$3,038.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,078.27
|
| Rate for Payer: Cash Price |
$1,973.25
|
| Rate for Payer: Cigna Commercial |
$3,275.60
|
| Rate for Payer: First Health Commercial |
$3,749.18
|
| Rate for Payer: Humana Commercial |
$3,354.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,236.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,912.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,183.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,472.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,959.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,223.42
|
| Rate for Payer: PHCS Commercial |
$3,788.64
|
| Rate for Payer: United Healthcare All Payer |
$3,472.92
|
|
|
AMBI PLATE 10 SLOT 130*220MM
|
Facility
|
IP
|
$3,764.15
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$489.34 |
| Max. Negotiated Rate |
$3,613.58 |
| Rate for Payer: Aetna Commercial |
$2,898.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,936.04
|
| Rate for Payer: Cash Price |
$1,882.08
|
| Rate for Payer: Cigna Commercial |
$3,124.24
|
| Rate for Payer: First Health Commercial |
$3,575.94
|
| Rate for Payer: Humana Commercial |
$3,199.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,086.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,777.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,129.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,312.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,823.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$752.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$489.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,166.89
|
| Rate for Payer: PHCS Commercial |
$3,613.58
|
| Rate for Payer: United Healthcare All Payer |
$3,312.45
|
|
