|
FIXED CORE J 150CM
|
Facility
|
OP
|
$144.41
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$138.63 |
| Rate for Payer: Aetna Commercial |
$111.20
|
| Rate for Payer: Anthem Medicaid |
$49.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.64
|
| Rate for Payer: Cash Price |
$72.21
|
| Rate for Payer: Cigna Commercial |
$119.86
|
| Rate for Payer: First Health Commercial |
$137.19
|
| Rate for Payer: Humana Commercial |
$122.75
|
| Rate for Payer: Humana KY Medicaid |
$49.66
|
| Rate for Payer: Kentucky WC Medicaid |
$50.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.08
|
| Rate for Payer: Ohio Health Group HMO |
$108.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.77
|
| Rate for Payer: PHCS Commercial |
$138.63
|
| Rate for Payer: United Healthcare All Payer |
$127.08
|
|
|
FIXED CORE J 260CM 49-168
|
Facility
|
OP
|
$485.90
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.17 |
| Max. Negotiated Rate |
$466.46 |
| Rate for Payer: Aetna Commercial |
$374.14
|
| Rate for Payer: Anthem Medicaid |
$167.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$379.00
|
| Rate for Payer: Cash Price |
$242.95
|
| Rate for Payer: Cigna Commercial |
$403.30
|
| Rate for Payer: First Health Commercial |
$461.60
|
| Rate for Payer: Humana Commercial |
$413.02
|
| Rate for Payer: Humana KY Medicaid |
$167.10
|
| Rate for Payer: Kentucky WC Medicaid |
$168.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$398.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$358.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$145.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$170.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$427.59
|
| Rate for Payer: Ohio Health Group HMO |
$364.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.63
|
| Rate for Payer: PHCS Commercial |
$466.46
|
| Rate for Payer: United Healthcare All Payer |
$427.59
|
|
|
FIXED CORE J 260CM 49-168
|
Facility
|
IP
|
$485.90
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.17 |
| Max. Negotiated Rate |
$466.46 |
| Rate for Payer: Aetna Commercial |
$374.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$379.00
|
| Rate for Payer: Cash Price |
$242.95
|
| Rate for Payer: Cigna Commercial |
$403.30
|
| Rate for Payer: First Health Commercial |
$461.60
|
| Rate for Payer: Humana Commercial |
$413.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$398.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$358.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$145.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$427.59
|
| Rate for Payer: Ohio Health Group HMO |
$364.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$150.63
|
| Rate for Payer: PHCS Commercial |
$466.46
|
| Rate for Payer: United Healthcare All Payer |
$427.59
|
|
|
FIX G/COLON TUBE W/DEVICE
|
Professional
|
Both
|
$2,949.75
|
|
|
Service Code
|
HCPCS 49460
|
| Hospital Charge Code |
76102010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$2,949.75 |
| Rate for Payer: Aetna Commercial |
$77.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.69
|
| Rate for Payer: Anthem Medicaid |
$39.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,949.75
|
| Rate for Payer: Cash Price |
$1,474.88
|
| Rate for Payer: Cash Price |
$1,474.88
|
| Rate for Payer: Cigna Commercial |
$70.12
|
| Rate for Payer: Healthspan PPO |
$979.09
|
| Rate for Payer: Humana Medicaid |
$39.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$63.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.94
|
| Rate for Payer: Molina Healthcare Passport |
$39.16
|
| Rate for Payer: Multiplan PHCS |
$1,769.85
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,064.82
|
| Rate for Payer: UHCCP Medicaid |
$45.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.55
|
|
|
FIX G/COLON TUBE W/DEVICE
|
Facility
|
OP
|
$2,949.75
|
|
|
Service Code
|
HCPCS 49460
|
| Hospital Charge Code |
76102010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.47 |
| Max. Negotiated Rate |
$2,831.76 |
| Rate for Payer: Aetna Commercial |
$2,271.31
|
| Rate for Payer: Anthem Medicaid |
$1,014.42
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,300.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$1,474.88
|
| Rate for Payer: Cash Price |
$1,474.88
|
| Rate for Payer: Cigna Commercial |
$2,448.29
|
| Rate for Payer: First Health Commercial |
$2,802.26
|
| Rate for Payer: Humana Commercial |
$2,507.29
|
| Rate for Payer: Humana KY Medicaid |
$1,014.42
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,418.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,176.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,595.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,212.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$589.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.42
|
| Rate for Payer: PHCS Commercial |
$2,831.76
|
| Rate for Payer: United Healthcare All Payer |
$2,595.78
|
|
|
FIX G/COLON TUBE W/DEVICE
|
Facility
|
IP
|
$2,949.75
|
|
|
Service Code
|
HCPCS 49460
|
| Hospital Charge Code |
76102010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$383.47 |
| Max. Negotiated Rate |
$2,831.76 |
| Rate for Payer: Aetna Commercial |
$2,271.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,300.80
|
| Rate for Payer: Cash Price |
$1,474.88
|
| Rate for Payer: Cigna Commercial |
$2,448.29
|
| Rate for Payer: First Health Commercial |
$2,802.26
|
| Rate for Payer: Humana Commercial |
$2,507.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,418.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,176.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,595.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,212.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$589.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$914.42
|
| Rate for Payer: PHCS Commercial |
$2,831.76
|
| Rate for Payer: United Healthcare All Payer |
$2,595.78
|
|
|
FIX G/COLON TUBE W/DEVICE(P
|
Professional
|
Both
|
$1,700.00
|
|
|
Service Code
|
HCPCS 49460
|
| Hospital Charge Code |
761P2010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$39.16 |
| Max. Negotiated Rate |
$1,700.00 |
| Rate for Payer: Aetna Commercial |
$77.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.69
|
| Rate for Payer: Anthem Medicaid |
$39.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,700.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$70.12
|
| Rate for Payer: Healthspan PPO |
$979.09
|
| Rate for Payer: Humana Medicaid |
$39.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$63.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$39.94
|
| Rate for Payer: Molina Healthcare Passport |
$39.16
|
| Rate for Payer: Multiplan PHCS |
$1,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,190.00
|
| Rate for Payer: UHCCP Medicaid |
$45.87
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$39.55
|
|
|
FIX G/COLON TUBE W/DEVICE(T
|
Facility
|
OP
|
$1,249.75
|
|
|
Service Code
|
HCPCS 49460
|
| Hospital Charge Code |
761T2010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.47 |
| Max. Negotiated Rate |
$1,199.76 |
| Rate for Payer: Aetna Commercial |
$962.31
|
| Rate for Payer: Anthem Medicaid |
$429.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$974.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$624.88
|
| Rate for Payer: Cash Price |
$624.88
|
| Rate for Payer: Cigna Commercial |
$1,037.29
|
| Rate for Payer: First Health Commercial |
$1,187.26
|
| Rate for Payer: Humana Commercial |
$1,062.29
|
| Rate for Payer: Humana KY Medicaid |
$429.79
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$434.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,024.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$438.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,099.78
|
| Rate for Payer: Ohio Health Group HMO |
$937.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.42
|
| Rate for Payer: PHCS Commercial |
$1,199.76
|
| Rate for Payer: United Healthcare All Payer |
$1,099.78
|
|
|
FIX G/COLON TUBE W/DEVICE(T
|
Facility
|
IP
|
$1,249.75
|
|
|
Service Code
|
HCPCS 49460
|
| Hospital Charge Code |
761T2010
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.47 |
| Max. Negotiated Rate |
$1,199.76 |
| Rate for Payer: Aetna Commercial |
$962.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$974.80
|
| Rate for Payer: Cash Price |
$624.88
|
| Rate for Payer: Cigna Commercial |
$1,037.29
|
| Rate for Payer: First Health Commercial |
$1,187.26
|
| Rate for Payer: Humana Commercial |
$1,062.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,024.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$374.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,099.78
|
| Rate for Payer: Ohio Health Group HMO |
$937.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$249.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$387.42
|
| Rate for Payer: PHCS Commercial |
$1,199.76
|
| Rate for Payer: United Healthcare All Payer |
$1,099.78
|
|
|
FLAGYL (METRONIDAZO 250MG/1TAB
|
Facility
|
IP
|
$4.61
|
|
|
Service Code
|
NDC 60687052601
|
| Hospital Charge Code |
25000678
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| 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 |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
FLAGYL (METRONIDAZO 250MG/1TAB
|
Facility
|
OP
|
$4.61
|
|
|
Service Code
|
NDC 60687052601
|
| Hospital Charge Code |
25000678
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.43 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.38
|
| Rate for Payer: Humana Commercial |
$3.92
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.06
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| 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 |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.43
|
| Rate for Payer: United Healthcare All Payer |
$4.06
|
|
|
FLAGYL (METRONIDAZO 500MG/1TAB
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 60687055001
|
| Hospital Charge Code |
25003068
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
FLAGYL (METRONIDAZO 500MG/1TAB
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 60687055001
|
| Hospital Charge Code |
25003068
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
FLASH ASP. CATH 16F100CM XTORQ
|
Facility
|
OP
|
$40,460.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,259.86 |
| Max. Negotiated Rate |
$38,842.08 |
| Rate for Payer: Aetna Commercial |
$31,154.58
|
| Rate for Payer: Anthem Medicaid |
$13,914.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,559.19
|
| Rate for Payer: Cash Price |
$20,230.25
|
| Rate for Payer: Cigna Commercial |
$33,582.22
|
| Rate for Payer: First Health Commercial |
$38,437.48
|
| Rate for Payer: Humana Commercial |
$34,391.42
|
| Rate for Payer: Humana KY Medicaid |
$13,914.37
|
| Rate for Payer: Kentucky WC Medicaid |
$14,055.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,177.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,859.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,138.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,193.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,605.24
|
| Rate for Payer: Ohio Health Group HMO |
$30,345.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,092.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,259.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,542.76
|
| Rate for Payer: PHCS Commercial |
$38,842.08
|
| Rate for Payer: United Healthcare All Payer |
$35,605.24
|
|
|
FLASH ASP. CATH 16F100CM XTORQ
|
Facility
|
IP
|
$40,460.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5,259.86 |
| Max. Negotiated Rate |
$38,842.08 |
| Rate for Payer: Aetna Commercial |
$31,154.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31,559.19
|
| Rate for Payer: Cash Price |
$20,230.25
|
| Rate for Payer: Cigna Commercial |
$33,582.22
|
| Rate for Payer: First Health Commercial |
$38,437.48
|
| Rate for Payer: Humana Commercial |
$34,391.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,177.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29,859.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,138.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$35,605.24
|
| Rate for Payer: Ohio Health Group HMO |
$30,345.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,092.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,259.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,542.76
|
| Rate for Payer: PHCS Commercial |
$38,842.08
|
| Rate for Payer: United Healthcare All Payer |
$35,605.24
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Professional
|
Both
|
$382.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
32000118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.82 |
| Max. Negotiated Rate |
$382.00 |
| Rate for Payer: Anthem Medicaid |
$25.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$382.00
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Humana Medicaid |
$25.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.65
|
| Rate for Payer: Molina Healthcare Passport |
$25.15
|
| Rate for Payer: Multiplan PHCS |
$229.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$267.40
|
| Rate for Payer: UHCCP Medicaid |
$133.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.40
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
320T0118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.16 |
| Max. Negotiated Rate |
$318.72 |
| Rate for Payer: Aetna Commercial |
$255.64
|
| Rate for Payer: Anthem Medicaid |
$114.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$258.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: First Health Commercial |
$315.40
|
| Rate for Payer: Humana Commercial |
$282.20
|
| Rate for Payer: Humana KY Medicaid |
$114.17
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$115.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$272.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$245.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$292.16
|
| Rate for Payer: Ohio Health Group HMO |
$249.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.92
|
| Rate for Payer: PHCS Commercial |
$318.72
|
| Rate for Payer: United Healthcare All Payer |
$292.16
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Facility
|
OP
|
$382.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
32000118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$49.66 |
| Max. Negotiated Rate |
$366.72 |
| Rate for Payer: Aetna Commercial |
$294.14
|
| Rate for Payer: Anthem Medicaid |
$131.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$317.06
|
| Rate for Payer: First Health Commercial |
$362.90
|
| Rate for Payer: Humana Commercial |
$324.70
|
| Rate for Payer: Humana KY Medicaid |
$131.37
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$132.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$313.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$134.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$336.16
|
| Rate for Payer: Ohio Health Group HMO |
$286.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$118.42
|
| Rate for Payer: PHCS Commercial |
$366.72
|
| Rate for Payer: United Healthcare All Payer |
$336.16
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
320T0118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$43.16 |
| Max. Negotiated Rate |
$318.72 |
| Rate for Payer: Aetna Commercial |
$255.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$258.96
|
| Rate for Payer: Cash Price |
$166.00
|
| Rate for Payer: Cigna Commercial |
$275.56
|
| Rate for Payer: First Health Commercial |
$315.40
|
| Rate for Payer: Humana Commercial |
$282.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$272.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$245.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$292.16
|
| Rate for Payer: Ohio Health Group HMO |
$249.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.92
|
| Rate for Payer: PHCS Commercial |
$318.72
|
| Rate for Payer: United Healthcare All Payer |
$292.16
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
320P0118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$14.82 |
| Max. Negotiated Rate |
$52.62 |
| Rate for Payer: Anthem Medicaid |
$25.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$52.62
|
| Rate for Payer: Humana Medicaid |
$25.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.65
|
| Rate for Payer: Molina Healthcare Passport |
$25.15
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$35.00
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.40
|
|
|
FLAT&UPRIGHABD COMP AP & ERECT
|
Facility
|
IP
|
$382.00
|
|
|
Service Code
|
HCPCS 74019
|
| Hospital Charge Code |
32000118
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$49.66 |
| Max. Negotiated Rate |
$366.72 |
| Rate for Payer: Aetna Commercial |
$294.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$297.96
|
| Rate for Payer: Cash Price |
$191.00
|
| Rate for Payer: Cigna Commercial |
$317.06
|
| Rate for Payer: First Health Commercial |
$362.90
|
| Rate for Payer: Humana Commercial |
$324.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$313.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$281.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$336.16
|
| Rate for Payer: Ohio Health Group HMO |
$286.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$118.42
|
| Rate for Payer: PHCS Commercial |
$366.72
|
| Rate for Payer: United Healthcare All Payer |
$336.16
|
|
|
FLEBOGAMMA 500mg(10gm) SDV
|
Facility
|
IP
|
$5,770.46
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$750.16 |
| Max. Negotiated Rate |
$5,539.64 |
| Rate for Payer: Aetna Commercial |
$4,443.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,500.96
|
| Rate for Payer: Cash Price |
$2,885.23
|
| Rate for Payer: Cigna Commercial |
$4,789.48
|
| Rate for Payer: First Health Commercial |
$5,481.94
|
| Rate for Payer: Humana Commercial |
$4,904.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,731.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,258.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,731.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,078.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,327.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,154.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,788.84
|
| Rate for Payer: PHCS Commercial |
$5,539.64
|
| Rate for Payer: United Healthcare All Payer |
$5,078.00
|
|
|
FLEBOGAMMA 500mg(10gm) SDV
|
Facility
|
OP
|
$5,770.46
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003829
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.12 |
| Max. Negotiated Rate |
$5,539.64 |
| Rate for Payer: Aetna Commercial |
$4,443.25
|
| Rate for Payer: Anthem Medicaid |
$1,984.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$56.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,500.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.76
|
| Rate for Payer: Cash Price |
$2,885.23
|
| Rate for Payer: Cash Price |
$2,885.23
|
| Rate for Payer: Cigna Commercial |
$4,789.48
|
| Rate for Payer: First Health Commercial |
$5,481.94
|
| Rate for Payer: Humana Commercial |
$4,904.89
|
| Rate for Payer: Humana KY Medicaid |
$1,984.46
|
| Rate for Payer: Humana Medicare Advantage |
$56.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,004.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,731.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,258.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,024.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,078.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,327.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,154.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$750.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,788.84
|
| Rate for Payer: PHCS Commercial |
$5,539.64
|
| Rate for Payer: United Healthcare All Payer |
$5,078.00
|
|
|
FLEBOGAMMA 500mg(20gm) SDV
|
Facility
|
OP
|
$11,540.92
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.12 |
| Max. Negotiated Rate |
$11,079.28 |
| Rate for Payer: Aetna Commercial |
$8,886.51
|
| Rate for Payer: Anthem Medicaid |
$3,968.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$56.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,001.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$78.56
|
| Rate for Payer: CareSource Just4Me Medicare |
$75.76
|
| Rate for Payer: Cash Price |
$5,770.46
|
| Rate for Payer: Cash Price |
$5,770.46
|
| Rate for Payer: Cigna Commercial |
$9,578.96
|
| Rate for Payer: First Health Commercial |
$10,963.87
|
| Rate for Payer: Humana Commercial |
$9,809.78
|
| Rate for Payer: Humana KY Medicaid |
$3,968.92
|
| Rate for Payer: Humana Medicare Advantage |
$56.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,009.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,463.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,517.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$67.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,048.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,156.01
|
| Rate for Payer: Ohio Health Group HMO |
$8,655.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,308.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,500.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,577.69
|
| Rate for Payer: PHCS Commercial |
$11,079.28
|
| Rate for Payer: United Healthcare All Payer |
$10,156.01
|
|
|
FLEBOGAMMA 500mg(20gm) SDV
|
Facility
|
IP
|
$11,540.92
|
|
|
Service Code
|
HCPCS J1572
|
| Hospital Charge Code |
25003830
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,500.32 |
| Max. Negotiated Rate |
$11,079.28 |
| Rate for Payer: Aetna Commercial |
$8,886.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,001.92
|
| Rate for Payer: Cash Price |
$5,770.46
|
| Rate for Payer: Cigna Commercial |
$9,578.96
|
| Rate for Payer: First Health Commercial |
$10,963.87
|
| Rate for Payer: Humana Commercial |
$9,809.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,463.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,517.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,462.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,156.01
|
| Rate for Payer: Ohio Health Group HMO |
$8,655.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,308.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,500.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,577.69
|
| Rate for Payer: PHCS Commercial |
$11,079.28
|
| Rate for Payer: United Healthcare All Payer |
$10,156.01
|
|
