|
LATUDA 20MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
25000846
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
| Rate for Payer: Aetna Commercial |
$65.67
|
|
|
LATUDA 40MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
25000847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 40MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
25000847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 60 MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030630
|
| Hospital Charge Code |
25004055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 60 MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030630
|
| Hospital Charge Code |
25004055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 80MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030830
|
| Hospital Charge Code |
25000848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 80MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030830
|
| Hospital Charge Code |
25000848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LAVH W/BSO
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
76102230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$6,985.45 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,989.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,985.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,735.97
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Humana Medicare Advantage |
$4,989.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,987.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
LAVH W/BSO
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
76102230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$649.94 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$1,341.68
|
| Rate for Payer: Anthem Medicaid |
$649.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,312.65
|
| Rate for Payer: Healthspan PPO |
$1,299.09
|
| Rate for Payer: Humana Medicaid |
$649.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,148.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$662.94
|
| Rate for Payer: Molina Healthcare Passport |
$649.94
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$656.44
|
|
|
LAVH W/BSO
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
76102230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
LAVH W/BSO(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 58550
|
| Hospital Charge Code |
761P2230
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$649.94 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$1,341.68
|
| Rate for Payer: Anthem Medicaid |
$649.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,312.65
|
| Rate for Payer: Healthspan PPO |
$1,299.09
|
| Rate for Payer: Humana Medicaid |
$649.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,148.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$662.94
|
| Rate for Payer: Molina Healthcare Passport |
$649.94
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$656.44
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
OP
|
$463.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
45000062
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$60.19 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$356.51
|
| Rate for Payer: Anthem Medicaid |
$159.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$361.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$231.50
|
| Rate for Payer: Cash Price |
$231.50
|
| Rate for Payer: Cigna Commercial |
$384.29
|
| Rate for Payer: First Health Commercial |
$439.85
|
| Rate for Payer: Humana Commercial |
$393.55
|
| Rate for Payer: Humana KY Medicaid |
$159.23
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$160.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$379.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$341.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$162.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$407.44
|
| Rate for Payer: Ohio Health Group HMO |
$347.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$143.53
|
| Rate for Payer: PHCS Commercial |
$444.48
|
| Rate for Payer: United Healthcare All Payer |
$407.44
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
IP
|
$833.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
76100139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.29 |
| Max. Negotiated Rate |
$799.68 |
| Rate for Payer: Aetna Commercial |
$641.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$649.74
|
| Rate for Payer: Cash Price |
$416.50
|
| Rate for Payer: Cigna Commercial |
$691.39
|
| Rate for Payer: First Health Commercial |
$791.35
|
| Rate for Payer: Humana Commercial |
$708.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$614.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$249.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.04
|
| Rate for Payer: Ohio Health Group HMO |
$624.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$166.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$258.23
|
| Rate for Payer: PHCS Commercial |
$799.68
|
| Rate for Payer: United Healthcare All Payer |
$733.04
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
OP
|
$833.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
76100139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.29 |
| Max. Negotiated Rate |
$799.68 |
| Rate for Payer: Aetna Commercial |
$641.41
|
| Rate for Payer: Anthem Medicaid |
$286.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$649.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$416.50
|
| Rate for Payer: Cash Price |
$416.50
|
| Rate for Payer: Cigna Commercial |
$691.39
|
| Rate for Payer: First Health Commercial |
$791.35
|
| Rate for Payer: Humana Commercial |
$708.05
|
| Rate for Payer: Humana KY Medicaid |
$286.47
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$289.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$683.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$614.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$292.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$733.04
|
| Rate for Payer: Ohio Health Group HMO |
$624.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$166.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$108.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$258.23
|
| Rate for Payer: PHCS Commercial |
$799.68
|
| Rate for Payer: United Healthcare All Payer |
$733.04
|
|
|
LAYER CLOSURE NK - HD - FT
|
Professional
|
Both
|
$833.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
76100139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$97.54 |
| Max. Negotiated Rate |
$833.00 |
| Rate for Payer: Aetna Commercial |
$278.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.80
|
| Rate for Payer: Anthem Medicaid |
$97.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$833.00
|
| Rate for Payer: Cash Price |
$416.50
|
| Rate for Payer: Cash Price |
$416.50
|
| Rate for Payer: Cigna Commercial |
$352.91
|
| Rate for Payer: Healthspan PPO |
$315.97
|
| Rate for Payer: Humana Medicaid |
$97.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.49
|
| Rate for Payer: Molina Healthcare Passport |
$97.54
|
| Rate for Payer: Multiplan PHCS |
$499.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$583.10
|
| Rate for Payer: UHCCP Medicaid |
$103.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.52
|
|
|
LAYER CLOSURE NK - HD - FT
|
Facility
|
IP
|
$463.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
45000062
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$60.19 |
| Max. Negotiated Rate |
$444.48 |
| Rate for Payer: Aetna Commercial |
$356.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$361.14
|
| Rate for Payer: Cash Price |
$231.50
|
| Rate for Payer: Cigna Commercial |
$384.29
|
| Rate for Payer: First Health Commercial |
$439.85
|
| Rate for Payer: Humana Commercial |
$393.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$379.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$341.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$407.44
|
| Rate for Payer: Ohio Health Group HMO |
$347.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$143.53
|
| Rate for Payer: PHCS Commercial |
$444.48
|
| Rate for Payer: United Healthcare All Payer |
$407.44
|
|
|
LAYER CLOSURE NK - HD - FT(P
|
Professional
|
Both
|
$370.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
761P0139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$97.54 |
| Max. Negotiated Rate |
$370.00 |
| Rate for Payer: Aetna Commercial |
$278.49
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$98.80
|
| Rate for Payer: Anthem Medicaid |
$97.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$370.00
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cash Price |
$185.00
|
| Rate for Payer: Cigna Commercial |
$352.91
|
| Rate for Payer: Healthspan PPO |
$315.97
|
| Rate for Payer: Humana Medicaid |
$97.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.49
|
| Rate for Payer: Molina Healthcare Passport |
$97.54
|
| Rate for Payer: Multiplan PHCS |
$222.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$259.00
|
| Rate for Payer: UHCCP Medicaid |
$103.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.52
|
|
|
LAYER CLOSURE NK - HD - FT(T
|
Facility
|
IP
|
$463.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
761T0139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.19 |
| Max. Negotiated Rate |
$444.48 |
| Rate for Payer: Aetna Commercial |
$356.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$361.14
|
| Rate for Payer: Cash Price |
$231.50
|
| Rate for Payer: Cigna Commercial |
$384.29
|
| Rate for Payer: First Health Commercial |
$439.85
|
| Rate for Payer: Humana Commercial |
$393.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$379.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$341.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$138.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$407.44
|
| Rate for Payer: Ohio Health Group HMO |
$347.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$143.53
|
| Rate for Payer: PHCS Commercial |
$444.48
|
| Rate for Payer: United Healthcare All Payer |
$407.44
|
|
|
LAYER CLOSURE NK - HD - FT(T
|
Facility
|
OP
|
$463.00
|
|
|
Service Code
|
HCPCS 12042
|
| Hospital Charge Code |
761T0139
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$60.19 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$356.51
|
| Rate for Payer: Anthem Medicaid |
$159.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$361.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$231.50
|
| Rate for Payer: Cash Price |
$231.50
|
| Rate for Payer: Cigna Commercial |
$384.29
|
| Rate for Payer: First Health Commercial |
$439.85
|
| Rate for Payer: Humana Commercial |
$393.55
|
| Rate for Payer: Humana KY Medicaid |
$159.23
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$160.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$379.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$341.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$162.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$407.44
|
| Rate for Payer: Ohio Health Group HMO |
$347.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$143.53
|
| Rate for Payer: PHCS Commercial |
$444.48
|
| Rate for Payer: United Healthcare All Payer |
$407.44
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$499.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
45000067
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem Medicaid |
$171.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Humana KY Medicaid |
$171.61
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$173.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
OP
|
$899.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
76100145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.87 |
| Max. Negotiated Rate |
$863.04 |
| Rate for Payer: Aetna Commercial |
$692.23
|
| Rate for Payer: Anthem Medicaid |
$309.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$701.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cigna Commercial |
$746.17
|
| Rate for Payer: First Health Commercial |
$854.05
|
| Rate for Payer: Humana Commercial |
$764.15
|
| Rate for Payer: Humana KY Medicaid |
$309.17
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$312.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$737.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$663.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$791.12
|
| Rate for Payer: Ohio Health Group HMO |
$674.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$179.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.69
|
| Rate for Payer: PHCS Commercial |
$863.04
|
| Rate for Payer: United Healthcare All Payer |
$791.12
|
|
|
LAYER CLOSURE OF WOUND
|
Professional
|
Both
|
$899.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
76100145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.32 |
| Max. Negotiated Rate |
$899.00 |
| Rate for Payer: Aetna Commercial |
$305.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$108.32
|
| Rate for Payer: Anthem Medicaid |
$141.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$899.00
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cigna Commercial |
$272.16
|
| Rate for Payer: Healthspan PPO |
$363.89
|
| Rate for Payer: Humana Medicaid |
$141.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.25
|
| Rate for Payer: Molina Healthcare Passport |
$141.42
|
| Rate for Payer: Multiplan PHCS |
$539.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$629.30
|
| Rate for Payer: UHCCP Medicaid |
$113.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$142.83
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$899.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
76100145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.87 |
| Max. Negotiated Rate |
$863.04 |
| Rate for Payer: Aetna Commercial |
$692.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$701.22
|
| Rate for Payer: Cash Price |
$449.50
|
| Rate for Payer: Cigna Commercial |
$746.17
|
| Rate for Payer: First Health Commercial |
$854.05
|
| Rate for Payer: Humana Commercial |
$764.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$737.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$663.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$791.12
|
| Rate for Payer: Ohio Health Group HMO |
$674.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$179.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$278.69
|
| Rate for Payer: PHCS Commercial |
$863.04
|
| Rate for Payer: United Healthcare All Payer |
$791.12
|
|
|
LAYER CLOSURE OF WOUND
|
Facility
|
IP
|
$499.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
45000067
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.87 |
| Max. Negotiated Rate |
$479.04 |
| Rate for Payer: Aetna Commercial |
$384.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$389.22
|
| Rate for Payer: Cash Price |
$249.50
|
| Rate for Payer: Cigna Commercial |
$414.17
|
| Rate for Payer: First Health Commercial |
$474.05
|
| Rate for Payer: Humana Commercial |
$424.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$409.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$368.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$439.12
|
| Rate for Payer: Ohio Health Group HMO |
$374.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$99.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$154.69
|
| Rate for Payer: PHCS Commercial |
$479.04
|
| Rate for Payer: United Healthcare All Payer |
$439.12
|
|
|
LAYER CLOSURE OF WOUND(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 12053
|
| Hospital Charge Code |
761P0145
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$108.32 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$305.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$108.32
|
| Rate for Payer: Anthem Medicaid |
$141.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$272.16
|
| Rate for Payer: Healthspan PPO |
$363.89
|
| Rate for Payer: Humana Medicaid |
$141.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$269.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$144.25
|
| Rate for Payer: Molina Healthcare Passport |
$141.42
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$113.74
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$142.83
|
|
