|
EVERFLEX ENTRUST 5F 8*150*150
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
EVERFLEX ENTRUST 5F 8*150*150
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
EVERFLEX ENTRUST 5F 8*20*150
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
EVERFLEX ENTRUST 5F 8*20*150
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
EVERFLEX ENTRUST 5F 8*40*150
|
Facility
|
OP
|
$11,849.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,554.78 |
| Max. Negotiated Rate |
$11,375.28 |
| Rate for Payer: Aetna Commercial |
$9,123.92
|
| Rate for Payer: Anthem Medicaid |
$4,074.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,242.42
|
| Rate for Payer: Cash Price |
$5,924.62
|
| Rate for Payer: Cigna Commercial |
$9,834.88
|
| Rate for Payer: First Health Commercial |
$11,256.79
|
| Rate for Payer: Humana Commercial |
$10,071.86
|
| Rate for Payer: Humana KY Medicaid |
$4,074.96
|
| Rate for Payer: Kentucky WC Medicaid |
$4,116.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,716.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,744.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,554.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,156.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,427.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,886.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,479.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,308.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,175.98
|
| Rate for Payer: PHCS Commercial |
$11,375.28
|
| Rate for Payer: United Healthcare All Payer |
$10,427.34
|
|
|
EVERFLEX ENTRUST 5F 8*40*150
|
Facility
|
IP
|
$11,849.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,554.78 |
| Max. Negotiated Rate |
$11,375.28 |
| Rate for Payer: Aetna Commercial |
$9,123.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,242.42
|
| Rate for Payer: Cash Price |
$5,924.62
|
| Rate for Payer: Cigna Commercial |
$9,834.88
|
| Rate for Payer: First Health Commercial |
$11,256.79
|
| Rate for Payer: Humana Commercial |
$10,071.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,716.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,744.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,554.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,427.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,886.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,479.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,308.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,175.98
|
| Rate for Payer: PHCS Commercial |
$11,375.28
|
| Rate for Payer: United Healthcare All Payer |
$10,427.34
|
|
|
EVERFLEX ENTRUST 5F 8*60*150
|
Facility
|
IP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
EVERFLEX ENTRUST 5F 8*60*150
|
Facility
|
OP
|
$5,468.75
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,640.62 |
| Max. Negotiated Rate |
$5,250.00 |
| Rate for Payer: Aetna Commercial |
$4,210.94
|
| Rate for Payer: Anthem Medicaid |
$1,880.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,265.62
|
| Rate for Payer: Cash Price |
$2,734.38
|
| Rate for Payer: Cigna Commercial |
$4,539.06
|
| Rate for Payer: First Health Commercial |
$5,195.31
|
| Rate for Payer: Humana Commercial |
$4,648.44
|
| Rate for Payer: Humana KY Medicaid |
$1,880.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,899.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,484.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,035.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,640.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,918.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,812.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,101.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,757.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,773.44
|
| Rate for Payer: PHCS Commercial |
$5,250.00
|
| Rate for Payer: United Healthcare All Payer |
$4,812.50
|
|
|
EVERFLEX ENTRUST 5F 8*80*150
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
EVERFLEX ENTRUST 5F 8*80*150
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
EVICEL 2ML
|
Facility
|
OP
|
$393.24
|
|
|
Service Code
|
NDC 63713039022
|
| Hospital Charge Code |
25003055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.97 |
| Max. Negotiated Rate |
$377.51 |
| Rate for Payer: Aetna Commercial |
$302.79
|
| Rate for Payer: Anthem Medicaid |
$135.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$306.73
|
| Rate for Payer: Cash Price |
$196.62
|
| Rate for Payer: Cigna Commercial |
$326.39
|
| Rate for Payer: First Health Commercial |
$373.58
|
| Rate for Payer: Humana Commercial |
$334.25
|
| Rate for Payer: Humana KY Medicaid |
$135.24
|
| Rate for Payer: Kentucky WC Medicaid |
$136.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$322.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$137.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.05
|
| Rate for Payer: Ohio Health Group HMO |
$294.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$314.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.34
|
| Rate for Payer: PHCS Commercial |
$377.51
|
| Rate for Payer: United Healthcare All Payer |
$346.05
|
|
|
EVICEL 2ML
|
Facility
|
IP
|
$393.24
|
|
|
Service Code
|
NDC 63713039022
|
| Hospital Charge Code |
25003055
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.97 |
| Max. Negotiated Rate |
$377.51 |
| Rate for Payer: Aetna Commercial |
$302.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$306.73
|
| Rate for Payer: Cash Price |
$196.62
|
| Rate for Payer: Cigna Commercial |
$326.39
|
| Rate for Payer: First Health Commercial |
$373.58
|
| Rate for Payer: Humana Commercial |
$334.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$322.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$290.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$346.05
|
| Rate for Payer: Ohio Health Group HMO |
$294.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$314.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$271.34
|
| Rate for Payer: PHCS Commercial |
$377.51
|
| Rate for Payer: United Healthcare All Payer |
$346.05
|
|
|
EVICEL 5ML
|
Facility
|
IP
|
$683.45
|
|
|
Service Code
|
NDC 63713039055
|
| Hospital Charge Code |
25003056
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.03 |
| Max. Negotiated Rate |
$656.11 |
| Rate for Payer: Aetna Commercial |
$526.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$533.09
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cigna Commercial |
$567.26
|
| Rate for Payer: First Health Commercial |
$649.28
|
| Rate for Payer: Humana Commercial |
$580.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$560.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$504.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$205.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$601.44
|
| Rate for Payer: Ohio Health Group HMO |
$512.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$546.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$594.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$471.58
|
| Rate for Payer: PHCS Commercial |
$656.11
|
| Rate for Payer: United Healthcare All Payer |
$601.44
|
|
|
EVICEL 5ML
|
Facility
|
OP
|
$683.45
|
|
|
Service Code
|
NDC 63713039055
|
| Hospital Charge Code |
25003056
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$205.03 |
| Max. Negotiated Rate |
$656.11 |
| Rate for Payer: Aetna Commercial |
$526.26
|
| Rate for Payer: Anthem Medicaid |
$235.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$533.09
|
| Rate for Payer: Cash Price |
$341.72
|
| Rate for Payer: Cigna Commercial |
$567.26
|
| Rate for Payer: First Health Commercial |
$649.28
|
| Rate for Payer: Humana Commercial |
$580.93
|
| Rate for Payer: Humana KY Medicaid |
$235.04
|
| Rate for Payer: Kentucky WC Medicaid |
$237.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$560.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$504.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$205.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$239.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$601.44
|
| Rate for Payer: Ohio Health Group HMO |
$512.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$546.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$594.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$471.58
|
| Rate for Payer: PHCS Commercial |
$656.11
|
| Rate for Payer: United Healthcare All Payer |
$601.44
|
|
|
EVISTA (RALOXIFENE) 60MG TAB
|
Facility
|
OP
|
$9.16
|
|
|
Service Code
|
NDC 65862070901
|
| Hospital Charge Code |
25000642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$7.05
|
| Rate for Payer: Anthem Medicaid |
$3.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: First Health Commercial |
$8.70
|
| Rate for Payer: Humana Commercial |
$7.79
|
| Rate for Payer: Humana KY Medicaid |
$3.15
|
| Rate for Payer: Kentucky WC Medicaid |
$3.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.06
|
| Rate for Payer: Ohio Health Group HMO |
$6.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.32
|
| Rate for Payer: PHCS Commercial |
$8.79
|
| Rate for Payer: United Healthcare All Payer |
$8.06
|
|
|
EVISTA (RALOXIFENE) 60MG TAB
|
Facility
|
IP
|
$9.16
|
|
|
Service Code
|
NDC 65862070901
|
| Hospital Charge Code |
25000642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$7.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: First Health Commercial |
$8.70
|
| Rate for Payer: Humana Commercial |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.06
|
| Rate for Payer: Ohio Health Group HMO |
$6.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.32
|
| Rate for Payer: PHCS Commercial |
$8.79
|
| Rate for Payer: United Healthcare All Payer |
$8.06
|
|
|
EVOKED OTOACOUSTIC EMISS LIMI
|
Facility
|
OP
|
$487.00
|
|
|
Service Code
|
HCPCS 92587
|
| Hospital Charge Code |
47000018
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$167.48 |
| Max. Negotiated Rate |
$467.52 |
| Rate for Payer: Aetna Commercial |
$374.99
|
| Rate for Payer: Anthem Medicaid |
$167.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$379.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cigna Commercial |
$404.21
|
| Rate for Payer: First Health Commercial |
$462.65
|
| Rate for Payer: Humana Commercial |
$413.95
|
| Rate for Payer: Humana KY Medicaid |
$167.48
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$169.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$399.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$359.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$170.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$428.56
|
| Rate for Payer: Ohio Health Group HMO |
$365.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$423.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.03
|
| Rate for Payer: PHCS Commercial |
$467.52
|
| Rate for Payer: United Healthcare All Payer |
$428.56
|
|
|
EVOKED OTOACOUSTIC EMISS LIMI
|
Facility
|
IP
|
$487.00
|
|
|
Service Code
|
HCPCS 92587
|
| Hospital Charge Code |
47000018
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$146.10 |
| Max. Negotiated Rate |
$467.52 |
| Rate for Payer: Aetna Commercial |
$374.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$379.86
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cigna Commercial |
$404.21
|
| Rate for Payer: First Health Commercial |
$462.65
|
| Rate for Payer: Humana Commercial |
$413.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$399.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$359.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$146.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$428.56
|
| Rate for Payer: Ohio Health Group HMO |
$365.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$423.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$336.03
|
| Rate for Payer: PHCS Commercial |
$467.52
|
| Rate for Payer: United Healthcare All Payer |
$428.56
|
|
|
EVOKED OTOACOUSTIC EMISS LIMI
|
Professional
|
Both
|
$487.00
|
|
|
Service Code
|
HCPCS 92587
|
| Hospital Charge Code |
47000018
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$292.20 |
| Rate for Payer: Aetna Commercial |
$59.93
|
| Rate for Payer: Ambetter Exchange |
$20.24
|
| Rate for Payer: Anthem Medicaid |
$43.18
|
| Rate for Payer: Buckeye Individual/Medicaid |
$20.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$20.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.29
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cash Price |
$243.50
|
| Rate for Payer: Cigna Commercial |
$81.56
|
| Rate for Payer: Healthspan PPO |
$49.05
|
| Rate for Payer: Humana Medicaid |
$43.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$20.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.04
|
| Rate for Payer: Molina Healthcare Passport |
$43.18
|
| Rate for Payer: Multiplan PHCS |
$292.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$26.31
|
| Rate for Payer: UHCCP Medicaid |
$170.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.24
|
|
|
EVOKED OTOACOUSTIC EMISS LIM(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 92587
|
| Hospital Charge Code |
470P0018
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$8.37 |
| Max. Negotiated Rate |
$81.56 |
| Rate for Payer: Aetna Commercial |
$59.93
|
| Rate for Payer: Ambetter Exchange |
$20.24
|
| Rate for Payer: Anthem Medicaid |
$43.18
|
| Rate for Payer: Buckeye Individual/Medicaid |
$20.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$20.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$24.29
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$81.56
|
| Rate for Payer: Healthspan PPO |
$49.05
|
| Rate for Payer: Humana Medicaid |
$43.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.37
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$20.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.04
|
| Rate for Payer: Molina Healthcare Passport |
$43.18
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$26.31
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$20.24
|
|
|
EVOKED OTOACOUSTIC EMISS LIM(T
|
Facility
|
OP
|
$387.00
|
|
|
Service Code
|
HCPCS 92587
|
| Hospital Charge Code |
470T0018
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$133.09 |
| Max. Negotiated Rate |
$402.82 |
| Rate for Payer: Aetna Commercial |
$297.99
|
| Rate for Payer: Anthem Medicaid |
$133.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$301.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$193.50
|
| Rate for Payer: Cash Price |
$193.50
|
| Rate for Payer: Cigna Commercial |
$321.21
|
| Rate for Payer: First Health Commercial |
$367.65
|
| Rate for Payer: Humana Commercial |
$328.95
|
| Rate for Payer: Humana KY Medicaid |
$133.09
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$134.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$317.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$285.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$135.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$340.56
|
| Rate for Payer: Ohio Health Group HMO |
$290.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$336.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.03
|
| Rate for Payer: PHCS Commercial |
$371.52
|
| Rate for Payer: United Healthcare All Payer |
$340.56
|
|
|
EVOKED OTOACOUSTIC EMISS LIM(T
|
Facility
|
IP
|
$387.00
|
|
|
Service Code
|
HCPCS 92587
|
| Hospital Charge Code |
470T0018
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$116.10 |
| Max. Negotiated Rate |
$371.52 |
| Rate for Payer: Aetna Commercial |
$297.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$301.86
|
| Rate for Payer: Cash Price |
$193.50
|
| Rate for Payer: Cigna Commercial |
$321.21
|
| Rate for Payer: First Health Commercial |
$367.65
|
| Rate for Payer: Humana Commercial |
$328.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$317.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$285.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$116.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$340.56
|
| Rate for Payer: Ohio Health Group HMO |
$290.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$336.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$267.03
|
| Rate for Payer: PHCS Commercial |
$371.52
|
| Rate for Payer: United Healthcare All Payer |
$340.56
|
|
|
EVOL CAN FILL STEM 17MM*100MM
|
Facility
|
IP
|
$8,296.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,488.84 |
| Max. Negotiated Rate |
$7,964.30 |
| Rate for Payer: Aetna Commercial |
$6,388.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,471.00
|
| Rate for Payer: Cash Price |
$4,148.08
|
| Rate for Payer: Cigna Commercial |
$6,885.80
|
| Rate for Payer: First Health Commercial |
$7,881.34
|
| Rate for Payer: Humana Commercial |
$7,051.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,802.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,122.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,488.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,300.61
|
| Rate for Payer: Ohio Health Group HMO |
$6,222.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,636.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,217.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,724.34
|
| Rate for Payer: PHCS Commercial |
$7,964.30
|
| Rate for Payer: United Healthcare All Payer |
$7,300.61
|
|
|
EVOL CAN FILL STEM 17MM*100MM
|
Facility
|
OP
|
$8,296.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,488.84 |
| Max. Negotiated Rate |
$7,964.30 |
| Rate for Payer: Aetna Commercial |
$6,388.04
|
| Rate for Payer: Anthem Medicaid |
$2,853.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,471.00
|
| Rate for Payer: Cash Price |
$4,148.08
|
| Rate for Payer: Cigna Commercial |
$6,885.80
|
| Rate for Payer: First Health Commercial |
$7,881.34
|
| Rate for Payer: Humana Commercial |
$7,051.73
|
| Rate for Payer: Humana KY Medicaid |
$2,853.05
|
| Rate for Payer: Kentucky WC Medicaid |
$2,882.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,802.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,122.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,488.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,910.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,300.61
|
| Rate for Payer: Ohio Health Group HMO |
$6,222.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,636.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,217.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,724.34
|
| Rate for Payer: PHCS Commercial |
$7,964.30
|
| Rate for Payer: United Healthcare All Payer |
$7,300.61
|
|
|
EVOL TIB AUG SZ 4MD RIGHT*10MM
|
Facility
|
OP
|
$8,332.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,499.80 |
| Max. Negotiated Rate |
$7,999.34 |
| Rate for Payer: Aetna Commercial |
$6,416.14
|
| Rate for Payer: Anthem Medicaid |
$2,865.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,499.47
|
| Rate for Payer: Cash Price |
$4,166.32
|
| Rate for Payer: Cigna Commercial |
$6,916.10
|
| Rate for Payer: First Health Commercial |
$7,916.02
|
| Rate for Payer: Humana Commercial |
$7,082.75
|
| Rate for Payer: Humana KY Medicaid |
$2,865.60
|
| Rate for Payer: Kentucky WC Medicaid |
$2,894.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,832.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,149.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,499.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,923.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,332.73
|
| Rate for Payer: Ohio Health Group HMO |
$6,249.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,666.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,249.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,749.53
|
| Rate for Payer: PHCS Commercial |
$7,999.34
|
| Rate for Payer: United Healthcare All Payer |
$7,332.73
|
|
