|
AMP FNGTHMBPRISECJNTPHLNXFLA(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
761P0757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.70 |
| Max. Negotiated Rate |
$1,112.78 |
| Rate for Payer: Aetna Commercial |
$909.55
|
| Rate for Payer: Ambetter Exchange |
$635.85
|
| Rate for Payer: Anthem Medicaid |
$300.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$635.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$635.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.02
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,112.78
|
| Rate for Payer: Healthspan PPO |
$823.86
|
| Rate for Payer: Humana Medicaid |
$300.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$783.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$635.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$635.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.71
|
| Rate for Payer: Molina Healthcare Passport |
$300.70
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$826.61
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$635.85
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
76100757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
76100757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$515.85 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
OP
|
$4,088.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
45000150
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,405.86 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$3,147.76
|
| Rate for Payer: Anthem Medicaid |
$1,405.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cigna Commercial |
$3,393.04
|
| Rate for Payer: First Health Commercial |
$3,883.60
|
| Rate for Payer: Humana Commercial |
$3,474.80
|
| Rate for Payer: Humana KY Medicaid |
$1,405.86
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,420.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,016.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,434.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,270.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,556.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,820.72
|
| Rate for Payer: PHCS Commercial |
$3,924.48
|
| Rate for Payer: United Healthcare All Payer |
$3,597.44
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Facility
|
IP
|
$4,088.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
45000150
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,226.40 |
| Max. Negotiated Rate |
$3,924.48 |
| Rate for Payer: Aetna Commercial |
$3,147.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.64
|
| Rate for Payer: Cash Price |
$2,044.00
|
| Rate for Payer: Cigna Commercial |
$3,393.04
|
| Rate for Payer: First Health Commercial |
$3,883.60
|
| Rate for Payer: Humana Commercial |
$3,474.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,016.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,226.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,270.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,556.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,820.72
|
| Rate for Payer: PHCS Commercial |
$3,924.48
|
| Rate for Payer: United Healthcare All Payer |
$3,597.44
|
|
|
AMP FNGTHMBPRISECJNTPHLNXFLAP
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 26952
|
| Hospital Charge Code |
76100757
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.70 |
| Max. Negotiated Rate |
$1,112.78 |
| Rate for Payer: Aetna Commercial |
$909.55
|
| Rate for Payer: Ambetter Exchange |
$635.85
|
| Rate for Payer: Anthem Medicaid |
$300.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$635.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$635.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.02
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,112.78
|
| Rate for Payer: Healthspan PPO |
$823.86
|
| Rate for Payer: Humana Medicaid |
$300.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$783.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$635.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$635.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$306.71
|
| Rate for Payer: Molina Healthcare Passport |
$300.70
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$826.61
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$303.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$635.85
|
|
|
AMPICILLIN 1GM IVPB PREMIX
|
Facility
|
OP
|
$114.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25003882
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.45 |
| Max. Negotiated Rate |
$110.23 |
| Rate for Payer: Aetna Commercial |
$88.41
|
| Rate for Payer: Anthem Medicaid |
$39.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.56
|
| Rate for Payer: Cash Price |
$57.41
|
| Rate for Payer: Cigna Commercial |
$95.30
|
| Rate for Payer: First Health Commercial |
$109.08
|
| Rate for Payer: Humana Commercial |
$97.60
|
| Rate for Payer: Humana KY Medicaid |
$39.49
|
| Rate for Payer: Kentucky WC Medicaid |
$39.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.04
|
| Rate for Payer: Ohio Health Group HMO |
$86.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.23
|
| Rate for Payer: PHCS Commercial |
$110.23
|
| Rate for Payer: United Healthcare All Payer |
$101.04
|
|
|
AMPICILLIN 1GM IVPB PREMIX
|
Facility
|
IP
|
$114.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25003882
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.45 |
| Max. Negotiated Rate |
$110.23 |
| Rate for Payer: Aetna Commercial |
$88.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.56
|
| Rate for Payer: Cash Price |
$57.41
|
| Rate for Payer: Cigna Commercial |
$95.30
|
| Rate for Payer: First Health Commercial |
$109.08
|
| Rate for Payer: Humana Commercial |
$97.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.04
|
| Rate for Payer: Ohio Health Group HMO |
$86.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.23
|
| Rate for Payer: PHCS Commercial |
$110.23
|
| Rate for Payer: United Healthcare All Payer |
$101.04
|
|
|
AMPICILLIN 500MG (1000MG SDV)
|
Facility
|
OP
|
$80.85
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.25 |
| Max. Negotiated Rate |
$77.62 |
| Rate for Payer: Aetna Commercial |
$62.25
|
| Rate for Payer: Anthem Medicaid |
$27.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.06
|
| Rate for Payer: Cash Price |
$40.42
|
| Rate for Payer: Cigna Commercial |
$67.11
|
| Rate for Payer: First Health Commercial |
$76.81
|
| Rate for Payer: Humana Commercial |
$68.72
|
| Rate for Payer: Humana KY Medicaid |
$27.80
|
| Rate for Payer: Kentucky WC Medicaid |
$28.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.15
|
| Rate for Payer: Ohio Health Group HMO |
$60.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.79
|
| Rate for Payer: PHCS Commercial |
$77.62
|
| Rate for Payer: United Healthcare All Payer |
$71.15
|
|
|
AMPICILLIN 500MG (1000MG SDV)
|
Facility
|
IP
|
$80.85
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001863
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.25 |
| Max. Negotiated Rate |
$77.62 |
| Rate for Payer: Aetna Commercial |
$62.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63.06
|
| Rate for Payer: Cash Price |
$40.42
|
| Rate for Payer: Cigna Commercial |
$67.11
|
| Rate for Payer: First Health Commercial |
$76.81
|
| Rate for Payer: Humana Commercial |
$68.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.15
|
| Rate for Payer: Ohio Health Group HMO |
$60.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.79
|
| Rate for Payer: PHCS Commercial |
$77.62
|
| Rate for Payer: United Healthcare All Payer |
$71.15
|
|
|
AMPICILLIN 500MG (500MG SDV)
|
Facility
|
IP
|
$78.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.65 |
| Max. Negotiated Rate |
$75.67 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.48
|
| Rate for Payer: Cash Price |
$39.41
|
| Rate for Payer: Cigna Commercial |
$65.42
|
| Rate for Payer: First Health Commercial |
$74.88
|
| Rate for Payer: Humana Commercial |
$67.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.39
|
| Rate for Payer: PHCS Commercial |
$75.67
|
| Rate for Payer: United Healthcare All Payer |
$69.36
|
|
|
AMPICILLIN 500MG (500MG SDV)
|
Facility
|
OP
|
$78.82
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001861
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.65 |
| Max. Negotiated Rate |
$75.67 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Anthem Medicaid |
$27.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.48
|
| Rate for Payer: Cash Price |
$39.41
|
| Rate for Payer: Cigna Commercial |
$65.42
|
| Rate for Payer: First Health Commercial |
$74.88
|
| Rate for Payer: Humana Commercial |
$67.00
|
| Rate for Payer: Humana KY Medicaid |
$27.11
|
| Rate for Payer: Kentucky WC Medicaid |
$27.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.36
|
| Rate for Payer: Ohio Health Group HMO |
$59.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.39
|
| Rate for Payer: PHCS Commercial |
$75.67
|
| Rate for Payer: United Healthcare All Payer |
$69.36
|
|
|
AMPICILLIN IV 500mg(2gm/20mL)
|
Facility
|
OP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25004194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.23 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem Medicaid |
$39.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.39
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Humana KY Medicaid |
$39.24
|
| Rate for Payer: Kentucky WC Medicaid |
$39.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.73
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPICILLIN IV 500mg(2gm/20mL)
|
Facility
|
IP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25004194
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.23 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.39
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.73
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPICILLIN IV 500MG(2GM/8ML)
|
Facility
|
IP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.23 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.39
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.73
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPICILLIN IV 500MG(2GM/8ML)
|
Facility
|
OP
|
$114.10
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
25001864
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.23 |
| Max. Negotiated Rate |
$109.54 |
| Rate for Payer: Aetna Commercial |
$87.86
|
| Rate for Payer: Anthem Medicaid |
$39.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.00
|
| Rate for Payer: Cash Price |
$57.05
|
| Rate for Payer: Cigna Commercial |
$94.70
|
| Rate for Payer: First Health Commercial |
$108.39
|
| Rate for Payer: Humana Commercial |
$96.98
|
| Rate for Payer: Humana KY Medicaid |
$39.24
|
| Rate for Payer: Kentucky WC Medicaid |
$39.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.41
|
| Rate for Payer: Ohio Health Group HMO |
$85.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.73
|
| Rate for Payer: PHCS Commercial |
$109.54
|
| Rate for Payer: United Healthcare All Payer |
$100.41
|
|
|
AMPLATZ EXTRA STIFF ST. .035
|
Facility
|
IP
|
$554.54
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$166.36 |
| Max. Negotiated Rate |
$532.36 |
| Rate for Payer: Aetna Commercial |
$427.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$432.54
|
| Rate for Payer: Cash Price |
$277.27
|
| Rate for Payer: Cigna Commercial |
$460.27
|
| Rate for Payer: First Health Commercial |
$526.81
|
| Rate for Payer: Humana Commercial |
$471.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$454.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$409.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$488.00
|
| Rate for Payer: Ohio Health Group HMO |
$415.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$382.63
|
| Rate for Payer: PHCS Commercial |
$532.36
|
| Rate for Payer: United Healthcare All Payer |
$488.00
|
|
|
AMPLATZ EXTRA STIFF ST. .035
|
Facility
|
OP
|
$554.54
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$166.36 |
| Max. Negotiated Rate |
$532.36 |
| Rate for Payer: Aetna Commercial |
$427.00
|
| Rate for Payer: Anthem Medicaid |
$190.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$432.54
|
| Rate for Payer: Cash Price |
$277.27
|
| Rate for Payer: Cigna Commercial |
$460.27
|
| Rate for Payer: First Health Commercial |
$526.81
|
| Rate for Payer: Humana Commercial |
$471.36
|
| Rate for Payer: Humana KY Medicaid |
$190.71
|
| Rate for Payer: Kentucky WC Medicaid |
$192.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$454.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$409.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$166.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$194.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$488.00
|
| Rate for Payer: Ohio Health Group HMO |
$415.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$382.63
|
| Rate for Payer: PHCS Commercial |
$532.36
|
| Rate for Payer: United Healthcare All Payer |
$488.00
|
|
|
AMPLATZ RENAL DILATOR/SHEATH S
|
Facility
|
IP
|
$3,005.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$901.50 |
| Max. Negotiated Rate |
$2,884.80 |
| Rate for Payer: Aetna Commercial |
$2,313.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,343.90
|
| Rate for Payer: Cash Price |
$1,502.50
|
| Rate for Payer: Cigna Commercial |
$2,494.15
|
| Rate for Payer: First Health Commercial |
$2,854.75
|
| Rate for Payer: Humana Commercial |
$2,554.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,464.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,217.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$901.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,644.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,253.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,404.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,614.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,073.45
|
| Rate for Payer: PHCS Commercial |
$2,884.80
|
| Rate for Payer: United Healthcare All Payer |
$2,644.40
|
|
|
AMPLATZ RENAL DILATOR/SHEATH S
|
Facility
|
OP
|
$3,005.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$901.50 |
| Max. Negotiated Rate |
$2,884.80 |
| Rate for Payer: Aetna Commercial |
$2,313.85
|
| Rate for Payer: Anthem Medicaid |
$1,033.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,343.90
|
| Rate for Payer: Cash Price |
$1,502.50
|
| Rate for Payer: Cigna Commercial |
$2,494.15
|
| Rate for Payer: First Health Commercial |
$2,854.75
|
| Rate for Payer: Humana Commercial |
$2,554.25
|
| Rate for Payer: Humana KY Medicaid |
$1,033.42
|
| Rate for Payer: Kentucky WC Medicaid |
$1,043.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,464.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,217.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$901.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,054.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,644.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,253.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,404.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,614.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,073.45
|
| Rate for Payer: PHCS Commercial |
$2,884.80
|
| Rate for Payer: United Healthcare All Payer |
$2,644.40
|
|
|
AMPLATZ SS .035*260
|
Facility
|
IP
|
$825.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| 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
|
|
|
AMPLATZ SS .035*260
|
Facility
|
OP
|
$825.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$247.50 |
| Max. Negotiated Rate |
$792.00 |
| Rate for Payer: Aetna Commercial |
$635.25
|
| Rate for Payer: Anthem Medicaid |
$283.72
|
| 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: Humana KY Medicaid |
$283.72
|
| Rate for Payer: Kentucky WC Medicaid |
$286.61
|
| 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: Molina Healthcare Medicaid |
$289.41
|
| 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
|
|
|
AMPLATZ SS .035*6*180
|
Facility
|
OP
|
$810.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.00 |
| Max. Negotiated Rate |
$777.60 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Anthem Medicaid |
$278.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.80
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$672.30
|
| Rate for Payer: First Health Commercial |
$769.50
|
| Rate for Payer: Humana Commercial |
$688.50
|
| Rate for Payer: Humana KY Medicaid |
$278.56
|
| Rate for Payer: Kentucky WC Medicaid |
$281.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.80
|
| Rate for Payer: Ohio Health Group HMO |
$607.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$704.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.90
|
| Rate for Payer: PHCS Commercial |
$777.60
|
| Rate for Payer: United Healthcare All Payer |
$712.80
|
|
|
AMPLATZ SS .035*6*180
|
Facility
|
IP
|
$810.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.00 |
| Max. Negotiated Rate |
$777.60 |
| Rate for Payer: Aetna Commercial |
$623.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$631.80
|
| Rate for Payer: Cash Price |
$405.00
|
| Rate for Payer: Cigna Commercial |
$672.30
|
| Rate for Payer: First Health Commercial |
$769.50
|
| Rate for Payer: Humana Commercial |
$688.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$664.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$597.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$712.80
|
| Rate for Payer: Ohio Health Group HMO |
$607.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$648.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$704.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.90
|
| Rate for Payer: PHCS Commercial |
$777.60
|
| Rate for Payer: United Healthcare All Payer |
$712.80
|
|
|
AMPLATZ SS 145CM
|
Facility
|
IP
|
$530.01
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$159.00 |
| Max. Negotiated Rate |
$508.81 |
| Rate for Payer: Aetna Commercial |
$408.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$413.41
|
| Rate for Payer: Cash Price |
$265.01
|
| Rate for Payer: Cigna Commercial |
$439.91
|
| Rate for Payer: First Health Commercial |
$503.51
|
| Rate for Payer: Humana Commercial |
$450.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$434.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$466.41
|
| Rate for Payer: Ohio Health Group HMO |
$397.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$365.71
|
| Rate for Payer: PHCS Commercial |
$508.81
|
| Rate for Payer: United Healthcare All Payer |
$466.41
|
|
