|
NEG PRESS WND THER >50CM DISP
|
Facility
|
OP
|
$546.00
|
|
|
Service Code
|
HCPCS 97608
|
| Hospital Charge Code |
76102505
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$524.16 |
| Rate for Payer: Aetna Commercial |
$420.42
|
| Rate for Payer: Anthem Medicaid |
$187.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cigna Commercial |
$453.18
|
| Rate for Payer: First Health Commercial |
$518.70
|
| Rate for Payer: Humana Commercial |
$464.10
|
| Rate for Payer: Humana KY Medicaid |
$187.77
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$189.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$447.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$480.48
|
| Rate for Payer: Ohio Health Group HMO |
$409.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.26
|
| Rate for Payer: PHCS Commercial |
$524.16
|
| Rate for Payer: United Healthcare All Payer |
$480.48
|
|
|
NEG PRESS WND THER >50CM DISP
|
Facility
|
OP
|
$546.00
|
|
|
Service Code
|
HCPCS 97608
|
| Hospital Charge Code |
42000077
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$524.16 |
| Rate for Payer: Aetna Commercial |
$420.42
|
| Rate for Payer: Anthem Medicaid |
$187.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cigna Commercial |
$453.18
|
| Rate for Payer: First Health Commercial |
$518.70
|
| Rate for Payer: Humana Commercial |
$464.10
|
| Rate for Payer: Humana KY Medicaid |
$187.77
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$189.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$447.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$191.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$480.48
|
| Rate for Payer: Ohio Health Group HMO |
$409.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.26
|
| Rate for Payer: PHCS Commercial |
$524.16
|
| Rate for Payer: United Healthcare All Payer |
$480.48
|
|
|
NEG PRESS WND THER >50CM DISP
|
Professional
|
Both
|
$546.00
|
|
|
Service Code
|
HCPCS 97608
|
| Hospital Charge Code |
76102505
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$20.31 |
| Max. Negotiated Rate |
$546.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$26.27
|
| Rate for Payer: Anthem Medicaid |
$20.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$546.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Humana Medicaid |
$20.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$38.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.72
|
| Rate for Payer: Molina Healthcare Passport |
$20.31
|
| Rate for Payer: Multiplan PHCS |
$327.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$382.20
|
| Rate for Payer: UHCCP Medicaid |
$27.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.51
|
|
|
NEG PRESS WND THER >50CM DISP
|
Facility
|
IP
|
$546.00
|
|
|
Service Code
|
HCPCS 97608
|
| Hospital Charge Code |
42000077
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$70.98 |
| Max. Negotiated Rate |
$524.16 |
| Rate for Payer: Aetna Commercial |
$420.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$425.88
|
| Rate for Payer: Cash Price |
$273.00
|
| Rate for Payer: Cigna Commercial |
$453.18
|
| Rate for Payer: First Health Commercial |
$518.70
|
| Rate for Payer: Humana Commercial |
$464.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$447.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$402.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$480.48
|
| Rate for Payer: Ohio Health Group HMO |
$409.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.26
|
| Rate for Payer: PHCS Commercial |
$524.16
|
| Rate for Payer: United Healthcare All Payer |
$480.48
|
|
|
NEOFORM 6*20
|
Facility
|
OP
|
$16,764.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,179.32 |
| Max. Negotiated Rate |
$16,093.44 |
| Rate for Payer: Aetna Commercial |
$12,908.28
|
| Rate for Payer: Anthem Medicaid |
$5,765.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,075.92
|
| Rate for Payer: Cash Price |
$8,382.00
|
| Rate for Payer: Cigna Commercial |
$13,914.12
|
| Rate for Payer: First Health Commercial |
$15,925.80
|
| Rate for Payer: Humana Commercial |
$14,249.40
|
| Rate for Payer: Humana KY Medicaid |
$5,765.14
|
| Rate for Payer: Kentucky WC Medicaid |
$5,823.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,746.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,371.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,029.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,880.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,752.32
|
| Rate for Payer: Ohio Health Group HMO |
$12,573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,352.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,179.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,196.84
|
| Rate for Payer: PHCS Commercial |
$16,093.44
|
| Rate for Payer: United Healthcare All Payer |
$14,752.32
|
|
|
NEOFORM 6*20
|
Facility
|
IP
|
$16,764.00
|
|
|
Service Code
|
HCPCS Q4100
|
| Hospital Charge Code |
27000114
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,179.32 |
| Max. Negotiated Rate |
$16,093.44 |
| Rate for Payer: Aetna Commercial |
$12,908.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,075.92
|
| Rate for Payer: Cash Price |
$8,382.00
|
| Rate for Payer: Cigna Commercial |
$13,914.12
|
| Rate for Payer: First Health Commercial |
$15,925.80
|
| Rate for Payer: Humana Commercial |
$14,249.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,746.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,371.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,029.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,752.32
|
| Rate for Payer: Ohio Health Group HMO |
$12,573.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,352.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,179.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,196.84
|
| Rate for Payer: PHCS Commercial |
$16,093.44
|
| Rate for Payer: United Healthcare All Payer |
$14,752.32
|
|
|
NEOMYCIN SULFATE 50 500MG/1TAB
|
Facility
|
IP
|
$9.11
|
|
|
Service Code
|
NDC 93117701
|
| Hospital Charge Code |
25001057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
NEOMYCIN SULFATE 50 500MG/1TAB
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 93117701
|
| Hospital Charge Code |
25001057
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
|
|
NEONATE CRIT CARE INITIAL
|
Professional
|
Both
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
51000124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$392.00 |
| Max. Negotiated Rate |
$1,404.86 |
| Rate for Payer: Aetna Commercial |
$1,390.23
|
| Rate for Payer: Anthem Medicaid |
$707.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,120.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$1,404.86
|
| Rate for Payer: Healthspan PPO |
$1,033.46
|
| Rate for Payer: Humana Medicaid |
$707.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,235.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$721.48
|
| Rate for Payer: Molina Healthcare Passport |
$707.33
|
| Rate for Payer: Multiplan PHCS |
$672.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$784.00
|
| Rate for Payer: UHCCP Medicaid |
$392.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$714.40
|
|
|
NEONATE CRIT CARE INITIAL
|
Facility
|
OP
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
51000124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$862.40
|
| Rate for Payer: Anthem Medicaid |
$385.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$873.60
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$929.60
|
| Rate for Payer: First Health Commercial |
$1,064.00
|
| Rate for Payer: Humana Commercial |
$952.00
|
| Rate for Payer: Humana KY Medicaid |
$385.17
|
| Rate for Payer: Kentucky WC Medicaid |
$389.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$918.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$826.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$392.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$985.60
|
| Rate for Payer: Ohio Health Group HMO |
$840.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$347.20
|
| Rate for Payer: PHCS Commercial |
$1,075.20
|
| Rate for Payer: United Healthcare All Payer |
$985.60
|
|
|
NEONATE CRIT CARE INITIAL
|
Facility
|
IP
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
51000124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$1,075.20 |
| Rate for Payer: Aetna Commercial |
$862.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$873.60
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$929.60
|
| Rate for Payer: First Health Commercial |
$1,064.00
|
| Rate for Payer: Humana Commercial |
$952.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$918.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$826.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$985.60
|
| Rate for Payer: Ohio Health Group HMO |
$840.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$224.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$347.20
|
| Rate for Payer: PHCS Commercial |
$1,075.20
|
| Rate for Payer: United Healthcare All Payer |
$985.60
|
|
|
NEONATE CRIT CARE INITIAL(P
|
Professional
|
Both
|
$1,120.00
|
|
|
Service Code
|
HCPCS 99468
|
| Hospital Charge Code |
510P0124
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$392.00 |
| Max. Negotiated Rate |
$1,404.86 |
| Rate for Payer: Aetna Commercial |
$1,390.23
|
| Rate for Payer: Anthem Medicaid |
$707.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,120.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cash Price |
$560.00
|
| Rate for Payer: Cigna Commercial |
$1,404.86
|
| Rate for Payer: Healthspan PPO |
$1,033.46
|
| Rate for Payer: Humana Medicaid |
$707.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,235.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$721.48
|
| Rate for Payer: Molina Healthcare Passport |
$707.33
|
| Rate for Payer: Multiplan PHCS |
$672.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$784.00
|
| Rate for Payer: UHCCP Medicaid |
$392.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$714.40
|
|
|
NEONATE CRIT CARE SUBSQ
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
NEONATE CRIT CARE SUBSQ
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$78.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$186.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
NEONATE CRIT CARE SUBSQ
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
51000125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$611.72 |
| Rate for Payer: Aetna Commercial |
$602.36
|
| Rate for Payer: Anthem Medicaid |
$308.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$611.72
|
| Rate for Payer: Healthspan PPO |
$447.77
|
| Rate for Payer: Humana Medicaid |
$308.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$535.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$314.74
|
| Rate for Payer: Molina Healthcare Passport |
$308.57
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$311.66
|
|
|
NEONATE CRIT CARE SUBSQ(P
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 99469
|
| Hospital Charge Code |
510P0125
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$611.72 |
| Rate for Payer: Aetna Commercial |
$602.36
|
| Rate for Payer: Anthem Medicaid |
$308.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$611.72
|
| Rate for Payer: Healthspan PPO |
$447.77
|
| Rate for Payer: Humana Medicaid |
$308.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$535.03
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$314.74
|
| Rate for Payer: Molina Healthcare Passport |
$308.57
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$311.66
|
|
|
NEONATES, DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY
|
Facility
|
IP
|
$21,283.72
|
|
|
Service Code
|
MSDRG 789
|
| Min. Negotiated Rate |
$14,442.53 |
| Max. Negotiated Rate |
$21,283.72 |
| Rate for Payer: Anthem Medicaid |
$14,442.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,202.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,283.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,523.59
|
| Rate for Payer: Humana KY Medicaid |
$14,442.53
|
| Rate for Payer: Humana Medicare Advantage |
$15,202.66
|
| Rate for Payer: Kentucky WC Medicaid |
$14,586.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,243.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,731.38
|
|
|
NEONATE WITH OTHER SIGNIFICANT PROBLEMS
|
Facility
|
IP
|
$17,429.15
|
|
|
Service Code
|
MSDRG 794
|
| Min. Negotiated Rate |
$11,826.92 |
| Max. Negotiated Rate |
$17,429.15 |
| Rate for Payer: Anthem Medicaid |
$11,826.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12,449.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17,429.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$16,806.68
|
| Rate for Payer: Humana KY Medicaid |
$11,826.92
|
| Rate for Payer: Humana Medicare Advantage |
$12,449.39
|
| Rate for Payer: Kentucky WC Medicaid |
$11,945.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14,939.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,063.46
|
|
|
NEOPOGEN 1 MCG (480 MGS/1.6ML)
|
Facility
|
OP
|
$2,732.25
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
25002060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2,622.96 |
| Rate for Payer: Aetna Commercial |
$2,103.83
|
| Rate for Payer: Anthem Medicaid |
$939.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,131.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1,366.12
|
| Rate for Payer: Cash Price |
$1,366.12
|
| Rate for Payer: Cigna Commercial |
$2,267.77
|
| Rate for Payer: First Health Commercial |
$2,595.64
|
| Rate for Payer: Humana Commercial |
$2,322.41
|
| Rate for Payer: Humana KY Medicaid |
$939.62
|
| Rate for Payer: Humana Medicare Advantage |
$0.99
|
| Rate for Payer: Kentucky WC Medicaid |
$949.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,240.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,016.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$958.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,404.38
|
| Rate for Payer: Ohio Health Group HMO |
$2,049.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$546.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$355.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$847.00
|
| Rate for Payer: PHCS Commercial |
$2,622.96
|
| Rate for Payer: United Healthcare All Payer |
$2,404.38
|
|
|
NEOPOGEN 1 MCG (480 MGS/1.6ML)
|
Facility
|
IP
|
$2,732.25
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
25002060
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$355.19 |
| Max. Negotiated Rate |
$2,622.96 |
| Rate for Payer: Aetna Commercial |
$2,103.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,131.16
|
| Rate for Payer: Cash Price |
$1,366.12
|
| Rate for Payer: Cigna Commercial |
$2,267.77
|
| Rate for Payer: First Health Commercial |
$2,595.64
|
| Rate for Payer: Humana Commercial |
$2,322.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,240.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,016.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$819.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,404.38
|
| Rate for Payer: Ohio Health Group HMO |
$2,049.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$546.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$355.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$847.00
|
| Rate for Payer: PHCS Commercial |
$2,622.96
|
| Rate for Payer: United Healthcare All Payer |
$2,404.38
|
|
|
NEORAL 100MG/ML OR SOL (50ML)
|
Facility
|
IP
|
$28.66
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002493
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$27.51 |
| Rate for Payer: Aetna Commercial |
$22.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.35
|
| Rate for Payer: Cash Price |
$14.33
|
| Rate for Payer: Cigna Commercial |
$23.79
|
| Rate for Payer: First Health Commercial |
$27.23
|
| Rate for Payer: Humana Commercial |
$24.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.22
|
| Rate for Payer: Ohio Health Group HMO |
$21.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.88
|
| Rate for Payer: PHCS Commercial |
$27.51
|
| Rate for Payer: United Healthcare All Payer |
$25.22
|
|
|
NEORAL 100MG/ML OR SOL (50ML)
|
Facility
|
OP
|
$28.66
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002493
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$27.51 |
| Rate for Payer: Aetna Commercial |
$22.07
|
| Rate for Payer: Anthem Medicaid |
$9.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.35
|
| Rate for Payer: Cash Price |
$14.33
|
| Rate for Payer: Cigna Commercial |
$23.79
|
| Rate for Payer: First Health Commercial |
$27.23
|
| Rate for Payer: Humana Commercial |
$24.36
|
| Rate for Payer: Humana KY Medicaid |
$9.86
|
| Rate for Payer: Kentucky WC Medicaid |
$9.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.22
|
| Rate for Payer: Ohio Health Group HMO |
$21.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.88
|
| Rate for Payer: PHCS Commercial |
$27.51
|
| Rate for Payer: United Healthcare All Payer |
$25.22
|
|
|
NEORAL(CYCLOSPORIN 100MG/CAP)
|
Facility
|
OP
|
$27.70
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$26.59 |
| Rate for Payer: Aetna Commercial |
$21.33
|
| Rate for Payer: Anthem Medicaid |
$9.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.61
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cigna Commercial |
$22.99
|
| Rate for Payer: First Health Commercial |
$26.32
|
| Rate for Payer: Humana Commercial |
$23.54
|
| Rate for Payer: Humana KY Medicaid |
$9.53
|
| Rate for Payer: Kentucky WC Medicaid |
$9.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.38
|
| Rate for Payer: Ohio Health Group HMO |
$20.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.59
|
| Rate for Payer: PHCS Commercial |
$26.59
|
| Rate for Payer: United Healthcare All Payer |
$24.38
|
|
|
NEORAL(CYCLOSPORIN 100MG/CAP)
|
Facility
|
IP
|
$27.70
|
|
|
Service Code
|
HCPCS J7502
|
| Hospital Charge Code |
25002492
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$26.59 |
| Rate for Payer: Aetna Commercial |
$21.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.61
|
| Rate for Payer: Cash Price |
$13.85
|
| Rate for Payer: Cigna Commercial |
$22.99
|
| Rate for Payer: First Health Commercial |
$26.32
|
| Rate for Payer: Humana Commercial |
$23.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.38
|
| Rate for Payer: Ohio Health Group HMO |
$20.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.59
|
| Rate for Payer: PHCS Commercial |
$26.59
|
| Rate for Payer: United Healthcare All Payer |
$24.38
|
|
|
NEORAL (CYCLOSPORINE 25MG/1CAP
|
Facility
|
OP
|
$9.10
|
|
|
Service Code
|
HCPCS J7515
|
| Hospital Charge Code |
25002503
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
