|
MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC
|
Facility
|
IP
|
$9,140.98
|
|
|
Service Code
|
MSDRG 641
|
| Min. Negotiated Rate |
$6,202.81 |
| Max. Negotiated Rate |
$9,140.98 |
| Rate for Payer: Anthem Medicaid |
$6,202.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,529.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,140.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,814.51
|
| Rate for Payer: Humana KY Medicaid |
$6,202.81
|
| Rate for Payer: Humana Medicare Advantage |
$6,529.27
|
| Rate for Payer: Kentucky WC Medicaid |
$6,264.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,835.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,326.86
|
|
|
MISC SPECIAL ST GROUP I
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
HCPCS 88312
|
| Hospital Charge Code |
30001512
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$243.84 |
| Rate for Payer: Aetna Commercial |
$195.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.96
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cigna Commercial |
$210.82
|
| Rate for Payer: First Health Commercial |
$241.30
|
| Rate for Payer: Humana Commercial |
$215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$208.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$187.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$223.52
|
| Rate for Payer: Ohio Health Group HMO |
$190.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.74
|
| Rate for Payer: PHCS Commercial |
$243.84
|
| Rate for Payer: United Healthcare All Payer |
$223.52
|
|
|
MISC SPECIAL ST GROUP I
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
HCPCS 88312
|
| Hospital Charge Code |
30001512
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$243.84 |
| Rate for Payer: Aetna Commercial |
$195.58
|
| Rate for Payer: Anthem Medicaid |
$87.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.26
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cigna Commercial |
$210.82
|
| Rate for Payer: First Health Commercial |
$241.30
|
| Rate for Payer: Humana Commercial |
$215.90
|
| Rate for Payer: Humana KY Medicaid |
$87.35
|
| Rate for Payer: Humana Medicare Advantage |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$88.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$208.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$187.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$89.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$223.52
|
| Rate for Payer: Ohio Health Group HMO |
$190.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.74
|
| Rate for Payer: PHCS Commercial |
$243.84
|
| Rate for Payer: United Healthcare All Payer |
$223.52
|
|
|
MISC SPECIAL ST GROUP I
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
HCPCS 88312
|
| Hospital Charge Code |
30001512
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$254.00 |
| Rate for Payer: Aetna Commercial |
$147.85
|
| Rate for Payer: Anthem Medicaid |
$71.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$254.00
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cigna Commercial |
$55.51
|
| Rate for Payer: Healthspan PPO |
$140.39
|
| Rate for Payer: Humana Medicaid |
$71.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.45
|
| Rate for Payer: Molina Healthcare Passport |
$71.03
|
| Rate for Payer: Multiplan PHCS |
$152.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.80
|
| Rate for Payer: UHCCP Medicaid |
$88.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.74
|
|
|
MIS TRAB METAL MOD TIB PLT SZ2
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ2
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ3
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ3
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ4
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ4
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ5
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ5
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ6
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ6
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ7
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ7
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ8
|
Facility
|
OP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem Medicaid |
$3,996.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Humana KY Medicaid |
$3,996.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,037.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,077.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
MIS TRAB METAL MOD TIB PLT SZ8
|
Facility
|
IP
|
$11,622.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,510.86 |
| Max. Negotiated Rate |
$11,157.12 |
| Rate for Payer: Aetna Commercial |
$8,948.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,065.16
|
| Rate for Payer: Cash Price |
$5,811.00
|
| Rate for Payer: Cigna Commercial |
$9,646.26
|
| Rate for Payer: First Health Commercial |
$11,040.90
|
| Rate for Payer: Humana Commercial |
$9,878.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,530.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,577.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,486.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,227.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,716.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,324.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,510.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,602.82
|
| Rate for Payer: PHCS Commercial |
$11,157.12
|
| Rate for Payer: United Healthcare All Payer |
$10,227.36
|
|
|
Mitomycin 0.1mg/mL EYE (Drop)
|
Facility
|
OP
|
$86.65
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$88.69 |
| Rate for Payer: Aetna Commercial |
$66.72
|
| Rate for Payer: Anthem Medicaid |
$29.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$63.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.59
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$88.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cigna Commercial |
$71.92
|
| Rate for Payer: First Health Commercial |
$82.32
|
| Rate for Payer: Humana Commercial |
$73.65
|
| Rate for Payer: Humana KY Medicaid |
$29.80
|
| Rate for Payer: Humana Medicare Advantage |
$63.35
|
| Rate for Payer: Kentucky WC Medicaid |
$30.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.25
|
| Rate for Payer: Ohio Health Group HMO |
$64.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.86
|
| Rate for Payer: PHCS Commercial |
$83.18
|
| Rate for Payer: United Healthcare All Payer |
$76.25
|
|
|
Mitomycin 0.1mg/mL EYE (Drop)
|
Facility
|
IP
|
$86.65
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$83.18 |
| Rate for Payer: Aetna Commercial |
$66.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.59
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cigna Commercial |
$71.92
|
| Rate for Payer: First Health Commercial |
$82.32
|
| Rate for Payer: Humana Commercial |
$73.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.25
|
| Rate for Payer: Ohio Health Group HMO |
$64.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.86
|
| Rate for Payer: PHCS Commercial |
$83.18
|
| Rate for Payer: United Healthcare All Payer |
$76.25
|
|
|
MITOMYCIN 5MG(40MG SDV)BLADDER
|
Facility
|
IP
|
$6,888.58
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$895.52 |
| Max. Negotiated Rate |
$6,613.04 |
| Rate for Payer: Aetna Commercial |
$5,304.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,373.09
|
| Rate for Payer: Cash Price |
$3,444.29
|
| Rate for Payer: Cigna Commercial |
$5,717.52
|
| Rate for Payer: First Health Commercial |
$6,544.15
|
| Rate for Payer: Humana Commercial |
$5,855.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.46
|
| Rate for Payer: PHCS Commercial |
$6,613.04
|
| Rate for Payer: United Healthcare All Payer |
$6,061.95
|
|
|
MITOMYCIN 5MG(40MG SDV)BLADDER
|
Facility
|
OP
|
$6,888.58
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$6,613.04 |
| Rate for Payer: Aetna Commercial |
$5,304.21
|
| Rate for Payer: Anthem Medicaid |
$2,368.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$63.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,373.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$88.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$3,444.29
|
| Rate for Payer: Cash Price |
$3,444.29
|
| Rate for Payer: Cigna Commercial |
$5,717.52
|
| Rate for Payer: First Health Commercial |
$6,544.15
|
| Rate for Payer: Humana Commercial |
$5,855.29
|
| Rate for Payer: Humana KY Medicaid |
$2,368.98
|
| Rate for Payer: Humana Medicare Advantage |
$63.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,393.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,416.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$895.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,135.46
|
| Rate for Payer: PHCS Commercial |
$6,613.04
|
| Rate for Payer: United Healthcare All Payer |
$6,061.95
|
|
|
MITOMYCIN BLADDER 20MG VIAL
|
Facility
|
IP
|
$3,444.40
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002660
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$447.77 |
| Max. Negotiated Rate |
$3,306.62 |
| Rate for Payer: Aetna Commercial |
$2,652.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.63
|
| Rate for Payer: Cash Price |
$1,722.20
|
| Rate for Payer: Cigna Commercial |
$2,858.85
|
| Rate for Payer: First Health Commercial |
$3,272.18
|
| Rate for Payer: Humana Commercial |
$2,927.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,033.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,031.07
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$688.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$447.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,067.76
|
| Rate for Payer: PHCS Commercial |
$3,306.62
|
| Rate for Payer: United Healthcare All Payer |
$3,031.07
|
|
|
MITOMYCIN BLADDER 20MG VIAL
|
Facility
|
OP
|
$3,444.40
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25002660
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$3,306.62 |
| Rate for Payer: Aetna Commercial |
$2,652.19
|
| Rate for Payer: Anthem Medicaid |
$1,184.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$63.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,686.63
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$88.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$85.52
|
| Rate for Payer: Cash Price |
$1,722.20
|
| Rate for Payer: Cash Price |
$1,722.20
|
| Rate for Payer: Cigna Commercial |
$2,858.85
|
| Rate for Payer: First Health Commercial |
$3,272.18
|
| Rate for Payer: Humana Commercial |
$2,927.74
|
| Rate for Payer: Humana KY Medicaid |
$1,184.53
|
| Rate for Payer: Humana Medicare Advantage |
$63.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,196.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,824.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,541.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,208.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,031.07
|
| Rate for Payer: Ohio Health Group HMO |
$2,583.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$688.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$447.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,067.76
|
| Rate for Payer: PHCS Commercial |
$3,306.62
|
| Rate for Payer: United Healthcare All Payer |
$3,031.07
|
|
|
MITOMYCIN BLADDER 5MG VIAL
|
Facility
|
OP
|
$1,325.82
|
|
|
Service Code
|
NDC 25021025020
|
| Hospital Charge Code |
25003213
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$172.36 |
| Max. Negotiated Rate |
$1,272.79 |
| Rate for Payer: Aetna Commercial |
$1,020.88
|
| Rate for Payer: Anthem Medicaid |
$455.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,034.14
|
| Rate for Payer: Cash Price |
$662.91
|
| Rate for Payer: Cigna Commercial |
$1,100.43
|
| Rate for Payer: First Health Commercial |
$1,259.53
|
| Rate for Payer: Humana Commercial |
$1,126.95
|
| Rate for Payer: Humana KY Medicaid |
$455.95
|
| Rate for Payer: Kentucky WC Medicaid |
$460.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,087.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$978.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$397.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$465.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,166.72
|
| Rate for Payer: Ohio Health Group HMO |
$994.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$265.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$172.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$411.00
|
| Rate for Payer: PHCS Commercial |
$1,272.79
|
| Rate for Payer: United Healthcare All Payer |
$1,166.72
|
|
