|
NYSTATIN CREAM (30GM)
|
Facility
|
OP
|
$2.94
|
|
|
Service Code
|
NDC 51672128902
|
| Hospital Charge Code |
25003310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna Commercial |
$2.26
|
| Rate for Payer: Anthem Medicaid |
$1.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.29
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cigna Commercial |
$2.44
|
| Rate for Payer: First Health Commercial |
$2.79
|
| Rate for Payer: Humana Commercial |
$2.50
|
| Rate for Payer: Humana KY Medicaid |
$1.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.59
|
| Rate for Payer: Ohio Health Group HMO |
$2.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.91
|
| Rate for Payer: PHCS Commercial |
$2.82
|
| Rate for Payer: United Healthcare All Payer |
$2.59
|
|
|
NYSTATIN CREAM (30GM)
|
Facility
|
IP
|
$2.94
|
|
|
Service Code
|
NDC 51672128902
|
| Hospital Charge Code |
25003310
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna Commercial |
$2.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.29
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cigna Commercial |
$2.44
|
| Rate for Payer: First Health Commercial |
$2.79
|
| Rate for Payer: Humana Commercial |
$2.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.59
|
| Rate for Payer: Ohio Health Group HMO |
$2.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.91
|
| Rate for Payer: PHCS Commercial |
$2.82
|
| Rate for Payer: United Healthcare All Payer |
$2.59
|
|
|
NYSTATIN ORAL SUSP 5ML500000U
|
Facility
|
IP
|
$9.89
|
|
|
Service Code
|
NDC 121086800
|
| Hospital Charge Code |
25001116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Aetna Commercial |
$7.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.71
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Cigna Commercial |
$8.21
|
| Rate for Payer: First Health Commercial |
$9.40
|
| Rate for Payer: Humana Commercial |
$8.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.70
|
| Rate for Payer: Ohio Health Group HMO |
$7.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$9.49
|
| Rate for Payer: United Healthcare All Payer |
$8.70
|
|
|
NYSTATIN ORAL SUSP 5ML500000U
|
Facility
|
OP
|
$9.89
|
|
|
Service Code
|
NDC 121086800
|
| Hospital Charge Code |
25001116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$9.49 |
| Rate for Payer: Aetna Commercial |
$7.62
|
| Rate for Payer: Anthem Medicaid |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.71
|
| Rate for Payer: Cash Price |
$4.94
|
| Rate for Payer: Cigna Commercial |
$8.21
|
| Rate for Payer: First Health Commercial |
$9.40
|
| Rate for Payer: Humana Commercial |
$8.41
|
| Rate for Payer: Humana KY Medicaid |
$3.40
|
| Rate for Payer: Kentucky WC Medicaid |
$3.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.70
|
| Rate for Payer: Ohio Health Group HMO |
$7.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$9.49
|
| Rate for Payer: United Healthcare All Payer |
$8.70
|
|
|
O2 SATURATION
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS 82810
|
| Hospital Charge Code |
30000335
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$46.08 |
| Rate for Payer: Aetna Commercial |
$36.96
|
| Rate for Payer: Anthem Medicaid |
$9.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$38.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.77
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.84
|
| Rate for Payer: First Health Commercial |
$45.60
|
| Rate for Payer: Humana Commercial |
$40.80
|
| Rate for Payer: Humana KY Medicaid |
$9.77
|
| Rate for Payer: Humana Medicare Advantage |
$9.77
|
| Rate for Payer: Kentucky WC Medicaid |
$9.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.24
|
| Rate for Payer: Ohio Health Group HMO |
$36.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.88
|
| Rate for Payer: PHCS Commercial |
$46.08
|
| Rate for Payer: United Healthcare All Payer |
$42.24
|
|
|
O2 SATURATION
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS 82810
|
| Hospital Charge Code |
30000335
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$46.08 |
| Rate for Payer: Aetna Commercial |
$36.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$38.54
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna Commercial |
$39.84
|
| Rate for Payer: First Health Commercial |
$45.60
|
| Rate for Payer: Humana Commercial |
$40.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$39.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$35.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$42.24
|
| Rate for Payer: Ohio Health Group HMO |
$36.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14.88
|
| Rate for Payer: PHCS Commercial |
$46.08
|
| Rate for Payer: United Healthcare All Payer |
$42.24
|
|
|
OAK TREE IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000923
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
OAK TREE IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000923
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
OB GROWTH
|
Facility
|
OP
|
$724.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
40200038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$94.12 |
| Max. Negotiated Rate |
$695.04 |
| Rate for Payer: Aetna Commercial |
$557.48
|
| Rate for Payer: Anthem Medicaid |
$248.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$564.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$362.00
|
| Rate for Payer: Cash Price |
$362.00
|
| Rate for Payer: Cigna Commercial |
$600.92
|
| Rate for Payer: First Health Commercial |
$687.80
|
| Rate for Payer: Humana Commercial |
$615.40
|
| Rate for Payer: Humana KY Medicaid |
$248.98
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$251.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$593.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$534.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$253.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$637.12
|
| Rate for Payer: Ohio Health Group HMO |
$543.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.44
|
| Rate for Payer: PHCS Commercial |
$695.04
|
| Rate for Payer: United Healthcare All Payer |
$637.12
|
|
|
OB GROWTH
|
Professional
|
Both
|
$724.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
40200038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$724.00 |
| Rate for Payer: Aetna Commercial |
$160.39
|
| Rate for Payer: Anthem Medicaid |
$80.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$724.00
|
| Rate for Payer: Cash Price |
$362.00
|
| Rate for Payer: Cash Price |
$362.00
|
| Rate for Payer: Cigna Commercial |
$142.08
|
| Rate for Payer: Healthspan PPO |
$150.28
|
| Rate for Payer: Humana Medicaid |
$80.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.73
|
| Rate for Payer: Molina Healthcare Passport |
$80.13
|
| Rate for Payer: Multiplan PHCS |
$434.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$506.80
|
| Rate for Payer: UHCCP Medicaid |
$253.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$80.93
|
|
|
OB GROWTH
|
Facility
|
IP
|
$724.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
40200038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$94.12 |
| Max. Negotiated Rate |
$695.04 |
| Rate for Payer: Aetna Commercial |
$557.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$564.72
|
| Rate for Payer: Cash Price |
$362.00
|
| Rate for Payer: Cigna Commercial |
$600.92
|
| Rate for Payer: First Health Commercial |
$687.80
|
| Rate for Payer: Humana Commercial |
$615.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$593.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$534.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$637.12
|
| Rate for Payer: Ohio Health Group HMO |
$543.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$224.44
|
| Rate for Payer: PHCS Commercial |
$695.04
|
| Rate for Payer: United Healthcare All Payer |
$637.12
|
|
|
OB GROWTH(P
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
402P0038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$160.39 |
| Rate for Payer: Aetna Commercial |
$160.39
|
| Rate for Payer: Anthem Medicaid |
$80.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$120.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$142.08
|
| Rate for Payer: Healthspan PPO |
$150.28
|
| Rate for Payer: Humana Medicaid |
$80.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$81.73
|
| Rate for Payer: Molina Healthcare Passport |
$80.13
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$80.93
|
|
|
OB GROWTH(T
|
Facility
|
IP
|
$604.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
402T0038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.52 |
| Max. Negotiated Rate |
$579.84 |
| Rate for Payer: Aetna Commercial |
$465.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.12
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$501.32
|
| Rate for Payer: First Health Commercial |
$573.80
|
| Rate for Payer: Humana Commercial |
$513.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$495.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$445.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$181.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$531.52
|
| Rate for Payer: Ohio Health Group HMO |
$453.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$187.24
|
| Rate for Payer: PHCS Commercial |
$579.84
|
| Rate for Payer: United Healthcare All Payer |
$531.52
|
|
|
OB GROWTH(T
|
Facility
|
OP
|
$604.00
|
|
|
Service Code
|
HCPCS 76816
|
| Hospital Charge Code |
402T0038
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$78.52 |
| Max. Negotiated Rate |
$579.84 |
| Rate for Payer: Aetna Commercial |
$465.08
|
| Rate for Payer: Anthem Medicaid |
$207.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$471.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cash Price |
$302.00
|
| Rate for Payer: Cigna Commercial |
$501.32
|
| Rate for Payer: First Health Commercial |
$573.80
|
| Rate for Payer: Humana Commercial |
$513.40
|
| Rate for Payer: Humana KY Medicaid |
$207.72
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$209.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$495.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$445.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$211.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$531.52
|
| Rate for Payer: Ohio Health Group HMO |
$453.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$187.24
|
| Rate for Payer: PHCS Commercial |
$579.84
|
| Rate for Payer: United Healthcare All Payer |
$531.52
|
|
|
OBLIQUE SUPPORT CONNECT
|
Facility
|
OP
|
$4,552.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$591.76 |
| Max. Negotiated Rate |
$4,369.92 |
| Rate for Payer: Aetna Commercial |
$3,505.04
|
| Rate for Payer: Anthem Medicaid |
$1,565.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,550.56
|
| Rate for Payer: Cash Price |
$2,276.00
|
| Rate for Payer: Cigna Commercial |
$3,778.16
|
| Rate for Payer: First Health Commercial |
$4,324.40
|
| Rate for Payer: Humana Commercial |
$3,869.20
|
| Rate for Payer: Humana KY Medicaid |
$1,565.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1,581.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,732.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,359.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,596.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,005.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,414.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$910.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$591.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,411.12
|
| Rate for Payer: PHCS Commercial |
$4,369.92
|
| Rate for Payer: United Healthcare All Payer |
$4,005.76
|
|
|
OBLIQUE SUPPORT CONNECT
|
Facility
|
IP
|
$4,552.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$591.76 |
| Max. Negotiated Rate |
$4,369.92 |
| Rate for Payer: Aetna Commercial |
$3,505.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,550.56
|
| Rate for Payer: Cash Price |
$2,276.00
|
| Rate for Payer: Cigna Commercial |
$3,778.16
|
| Rate for Payer: First Health Commercial |
$4,324.40
|
| Rate for Payer: Humana Commercial |
$3,869.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,732.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,359.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,365.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,005.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,414.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$910.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$591.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,411.12
|
| Rate for Payer: PHCS Commercial |
$4,369.92
|
| Rate for Payer: United Healthcare All Payer |
$4,005.76
|
|
|
OBLITER OF RT BREAST FAT NECRO
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
76102736
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Anthem Medicaid |
$250.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$250.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$255.00
|
| Rate for Payer: Molina Healthcare Passport |
$250.00
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$252.50
|
|
|
OBS ADMT/DC SAME DAY LV 1
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 99234
|
| Hospital Charge Code |
76200008
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$202.01 |
| Rate for Payer: Aetna Commercial |
$202.01
|
| Rate for Payer: Anthem Medicaid |
$102.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$191.14
|
| Rate for Payer: Healthspan PPO |
$150.17
|
| Rate for Payer: Humana Medicaid |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$180.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.85
|
| Rate for Payer: Molina Healthcare Passport |
$102.79
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.82
|
|
|
OBS ADMT/DC SAME DAY LV 1(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 99234
|
| Hospital Charge Code |
762P0008
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$202.01 |
| Rate for Payer: Aetna Commercial |
$202.01
|
| Rate for Payer: Anthem Medicaid |
$102.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$191.14
|
| Rate for Payer: Healthspan PPO |
$150.17
|
| Rate for Payer: Humana Medicaid |
$102.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$180.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$104.85
|
| Rate for Payer: Molina Healthcare Passport |
$102.79
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$103.82
|
|
|
OBS ADMT/DC SAME DAY LV 2
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
HCPCS 99235
|
| Hospital Charge Code |
76200009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$265.00 |
| Rate for Payer: Aetna Commercial |
$265.00
|
| Rate for Payer: Anthem Medicaid |
$135.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$264.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Healthspan PPO |
$196.99
|
| Rate for Payer: Humana Medicaid |
$135.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$235.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$138.38
|
| Rate for Payer: Molina Healthcare Passport |
$135.67
|
| Rate for Payer: Multiplan PHCS |
$158.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$184.80
|
| Rate for Payer: UHCCP Medicaid |
$92.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$137.03
|
|
|
OBS ADMT/DC SAME DAY LV 2(P
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
HCPCS 99235
|
| Hospital Charge Code |
762P0009
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$92.40 |
| Max. Negotiated Rate |
$265.00 |
| Rate for Payer: Aetna Commercial |
$265.00
|
| Rate for Payer: Anthem Medicaid |
$135.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$264.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna Commercial |
$252.08
|
| Rate for Payer: Healthspan PPO |
$196.99
|
| Rate for Payer: Humana Medicaid |
$135.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$235.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$138.38
|
| Rate for Payer: Molina Healthcare Passport |
$135.67
|
| Rate for Payer: Multiplan PHCS |
$158.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$184.80
|
| Rate for Payer: UHCCP Medicaid |
$92.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$137.03
|
|
|
OBS ADMT/DC SAME DAY LV 3
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS 99236
|
| Hospital Charge Code |
76200010
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$329.05 |
| Rate for Payer: Aetna Commercial |
$329.05
|
| Rate for Payer: Anthem Medicaid |
$169.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$310.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cigna Commercial |
$314.10
|
| Rate for Payer: Healthspan PPO |
$244.60
|
| Rate for Payer: Humana Medicaid |
$169.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$293.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.71
|
| Rate for Payer: Molina Healthcare Passport |
$169.32
|
| Rate for Payer: Multiplan PHCS |
$186.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$217.00
|
| Rate for Payer: UHCCP Medicaid |
$108.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.01
|
|
|
OBS ADMT/DC SAME DAY LV 3(P
|
Professional
|
Both
|
$310.00
|
|
|
Service Code
|
HCPCS 99236
|
| Hospital Charge Code |
762P0010
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$108.50 |
| Max. Negotiated Rate |
$329.05 |
| Rate for Payer: Aetna Commercial |
$329.05
|
| Rate for Payer: Anthem Medicaid |
$169.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$310.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cash Price |
$155.00
|
| Rate for Payer: Cigna Commercial |
$314.10
|
| Rate for Payer: Healthspan PPO |
$244.60
|
| Rate for Payer: Humana Medicaid |
$169.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$293.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.71
|
| Rate for Payer: Molina Healthcare Passport |
$169.32
|
| Rate for Payer: Multiplan PHCS |
$186.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$217.00
|
| Rate for Payer: UHCCP Medicaid |
$108.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.01
|
|
|
OBSERVATION ADDTL HRS EA
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
76200011
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
OBSERVATION ADDTL HRS EA
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS G0378
|
| Hospital Charge Code |
76200011
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem Medicaid |
$15.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Humana KY Medicaid |
$15.48
|
| Rate for Payer: Kentucky WC Medicaid |
$15.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.95
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
