|
PEDCLE FH/CH/CH/M/N/AX/G/H/F
|
Professional
|
Both
|
$6,196.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
76100199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$298.15 |
| Max. Negotiated Rate |
$6,196.00 |
| Rate for Payer: Aetna Commercial |
$1,097.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$376.34
|
| Rate for Payer: Anthem Medicaid |
$298.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,196.00
|
| Rate for Payer: Cash Price |
$3,098.00
|
| Rate for Payer: Cash Price |
$3,098.00
|
| Rate for Payer: Cigna Commercial |
$1,045.61
|
| Rate for Payer: Healthspan PPO |
$1,013.11
|
| Rate for Payer: Humana Medicaid |
$298.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$958.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$304.11
|
| Rate for Payer: Molina Healthcare Passport |
$298.15
|
| Rate for Payer: Multiplan PHCS |
$3,717.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,337.20
|
| Rate for Payer: UHCCP Medicaid |
$395.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$301.13
|
|
|
PEDCLE FH/CH/CH/M/N/AX/G/H/F
|
Facility
|
OP
|
$6,196.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
76100199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$805.48 |
| Max. Negotiated Rate |
$5,948.16 |
| Rate for Payer: Aetna Commercial |
$4,770.92
|
| Rate for Payer: Anthem Medicaid |
$2,130.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,832.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$3,098.00
|
| Rate for Payer: Cash Price |
$3,098.00
|
| Rate for Payer: Cigna Commercial |
$5,142.68
|
| Rate for Payer: First Health Commercial |
$5,886.20
|
| Rate for Payer: Humana Commercial |
$5,266.60
|
| Rate for Payer: Humana KY Medicaid |
$2,130.80
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,152.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,080.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,572.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,173.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,452.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,647.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,239.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$805.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,920.76
|
| Rate for Payer: PHCS Commercial |
$5,948.16
|
| Rate for Payer: United Healthcare All Payer |
$5,452.48
|
|
|
PEDCLE FH/CH/CH/M/N/AX/G/H/F
|
Facility
|
IP
|
$6,196.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
76100199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$805.48 |
| Max. Negotiated Rate |
$5,948.16 |
| Rate for Payer: Aetna Commercial |
$4,770.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,832.88
|
| Rate for Payer: Cash Price |
$3,098.00
|
| Rate for Payer: Cigna Commercial |
$5,142.68
|
| Rate for Payer: First Health Commercial |
$5,886.20
|
| Rate for Payer: Humana Commercial |
$5,266.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,080.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,572.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,858.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,452.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,647.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,239.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$805.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,920.76
|
| Rate for Payer: PHCS Commercial |
$5,948.16
|
| Rate for Payer: United Healthcare All Payer |
$5,452.48
|
|
|
PEDCLE FH/CH/CH/M/N/AX/G/H/(P
|
Professional
|
Both
|
$1,975.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
761P0199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$298.15 |
| Max. Negotiated Rate |
$1,975.00 |
| Rate for Payer: Aetna Commercial |
$1,097.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$376.34
|
| Rate for Payer: Anthem Medicaid |
$298.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,975.00
|
| Rate for Payer: Cash Price |
$987.50
|
| Rate for Payer: Cash Price |
$987.50
|
| Rate for Payer: Cigna Commercial |
$1,045.61
|
| Rate for Payer: Healthspan PPO |
$1,013.11
|
| Rate for Payer: Humana Medicaid |
$298.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$958.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$304.11
|
| Rate for Payer: Molina Healthcare Passport |
$298.15
|
| Rate for Payer: Multiplan PHCS |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,382.50
|
| Rate for Payer: UHCCP Medicaid |
$395.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$301.13
|
|
|
PEDCLE FH/CH/CH/M/N/AX/G/H/(T
|
Facility
|
OP
|
$4,221.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
761T0199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$548.73 |
| Max. Negotiated Rate |
$4,052.16 |
| Rate for Payer: Aetna Commercial |
$3,250.17
|
| Rate for Payer: Anthem Medicaid |
$1,451.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,292.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,110.50
|
| Rate for Payer: Cash Price |
$2,110.50
|
| Rate for Payer: Cigna Commercial |
$3,503.43
|
| Rate for Payer: First Health Commercial |
$4,009.95
|
| Rate for Payer: Humana Commercial |
$3,587.85
|
| Rate for Payer: Humana KY Medicaid |
$1,451.60
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,466.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,461.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,115.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,480.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,714.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,165.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$844.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,308.51
|
| Rate for Payer: PHCS Commercial |
$4,052.16
|
| Rate for Payer: United Healthcare All Payer |
$3,714.48
|
|
|
PEDCLE FH/CH/CH/M/N/AX/G/H/(T
|
Facility
|
IP
|
$4,221.00
|
|
|
Service Code
|
HCPCS 15574
|
| Hospital Charge Code |
761T0199
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$548.73 |
| Max. Negotiated Rate |
$4,052.16 |
| Rate for Payer: Aetna Commercial |
$3,250.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,292.38
|
| Rate for Payer: Cash Price |
$2,110.50
|
| Rate for Payer: Cigna Commercial |
$3,503.43
|
| Rate for Payer: First Health Commercial |
$4,009.95
|
| Rate for Payer: Humana Commercial |
$3,587.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,461.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,115.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,266.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,714.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,165.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$844.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$548.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,308.51
|
| Rate for Payer: PHCS Commercial |
$4,052.16
|
| Rate for Payer: United Healthcare All Payer |
$3,714.48
|
|
|
PED CRIT CARE TRANSPORT
|
Professional
|
Both
|
$440.00
|
|
|
Service Code
|
HCPCS 99466
|
| Hospital Charge Code |
51000122
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$154.00 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna Commercial |
$368.56
|
| Rate for Payer: Anthem Medicaid |
$190.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$440.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cigna Commercial |
$373.60
|
| Rate for Payer: Healthspan PPO |
$273.97
|
| Rate for Payer: Humana Medicaid |
$190.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$369.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$193.98
|
| Rate for Payer: Molina Healthcare Passport |
$190.18
|
| Rate for Payer: Multiplan PHCS |
$264.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$308.00
|
| Rate for Payer: UHCCP Medicaid |
$154.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.08
|
|
|
PED CRIT CARE TRANSPORT
|
Facility
|
IP
|
$440.00
|
|
|
Service Code
|
HCPCS 99466
|
| Hospital Charge Code |
51000122
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.20 |
| Max. Negotiated Rate |
$422.40 |
| Rate for Payer: Aetna Commercial |
$338.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.20
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cigna Commercial |
$365.20
|
| Rate for Payer: First Health Commercial |
$418.00
|
| Rate for Payer: Humana Commercial |
$374.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$360.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.20
|
| Rate for Payer: Ohio Health Group HMO |
$330.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.40
|
| Rate for Payer: PHCS Commercial |
$422.40
|
| Rate for Payer: United Healthcare All Payer |
$387.20
|
|
|
PED CRIT CARE TRANSPORT
|
Facility
|
OP
|
$440.00
|
|
|
Service Code
|
HCPCS 99466
|
| Hospital Charge Code |
51000122
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.20 |
| Max. Negotiated Rate |
$422.40 |
| Rate for Payer: Aetna Commercial |
$338.80
|
| Rate for Payer: Anthem Medicaid |
$151.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.20
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cigna Commercial |
$365.20
|
| Rate for Payer: First Health Commercial |
$418.00
|
| Rate for Payer: Humana Commercial |
$374.00
|
| Rate for Payer: Humana KY Medicaid |
$151.32
|
| Rate for Payer: Kentucky WC Medicaid |
$152.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$360.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$154.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.20
|
| Rate for Payer: Ohio Health Group HMO |
$330.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$88.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$136.40
|
| Rate for Payer: PHCS Commercial |
$422.40
|
| Rate for Payer: United Healthcare All Payer |
$387.20
|
|
|
PED CRIT CARE TRANSPORT ADDL
|
Facility
|
IP
|
$320.00
|
|
|
Service Code
|
HCPCS 99467
|
| Hospital Charge Code |
51000123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$307.20 |
| Rate for Payer: Aetna Commercial |
$246.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.60
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: First Health Commercial |
$304.00
|
| Rate for Payer: Humana Commercial |
$272.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$281.60
|
| Rate for Payer: Ohio Health Group HMO |
$240.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.20
|
| Rate for Payer: PHCS Commercial |
$307.20
|
| Rate for Payer: United Healthcare All Payer |
$281.60
|
|
|
PED CRIT CARE TRANSPORT ADDL
|
Professional
|
Both
|
$320.00
|
|
|
Service Code
|
HCPCS 99467
|
| Hospital Charge Code |
51000123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$94.05 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$184.03
|
| Rate for Payer: Anthem Medicaid |
$94.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$320.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$186.54
|
| Rate for Payer: Healthspan PPO |
$136.80
|
| Rate for Payer: Humana Medicaid |
$94.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.93
|
| Rate for Payer: Molina Healthcare Passport |
$94.05
|
| Rate for Payer: Multiplan PHCS |
$192.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.00
|
| Rate for Payer: UHCCP Medicaid |
$112.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.99
|
|
|
PED CRIT CARE TRANSPORT ADDL
|
Facility
|
OP
|
$320.00
|
|
|
Service Code
|
HCPCS 99467
|
| Hospital Charge Code |
51000123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.60 |
| Max. Negotiated Rate |
$307.20 |
| Rate for Payer: Aetna Commercial |
$246.40
|
| Rate for Payer: Anthem Medicaid |
$110.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.60
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$265.60
|
| Rate for Payer: First Health Commercial |
$304.00
|
| Rate for Payer: Humana Commercial |
$272.00
|
| Rate for Payer: Humana KY Medicaid |
$110.05
|
| Rate for Payer: Kentucky WC Medicaid |
$111.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$281.60
|
| Rate for Payer: Ohio Health Group HMO |
$240.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.20
|
| Rate for Payer: PHCS Commercial |
$307.20
|
| Rate for Payer: United Healthcare All Payer |
$281.60
|
|
|
PED CRIT CARE TRANSPORT ADD(P
|
Professional
|
Both
|
$320.00
|
|
|
Service Code
|
HCPCS 99467
|
| Hospital Charge Code |
510P0123
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$94.05 |
| Max. Negotiated Rate |
$320.00 |
| Rate for Payer: Aetna Commercial |
$184.03
|
| Rate for Payer: Anthem Medicaid |
$94.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$320.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cash Price |
$160.00
|
| Rate for Payer: Cigna Commercial |
$186.54
|
| Rate for Payer: Healthspan PPO |
$136.80
|
| Rate for Payer: Humana Medicaid |
$94.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.20
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.93
|
| Rate for Payer: Molina Healthcare Passport |
$94.05
|
| Rate for Payer: Multiplan PHCS |
$192.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$224.00
|
| Rate for Payer: UHCCP Medicaid |
$112.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.99
|
|
|
PED CRIT CARE TRANSPORT(P
|
Professional
|
Both
|
$440.00
|
|
|
Service Code
|
HCPCS 99466
|
| Hospital Charge Code |
510P0122
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$154.00 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna Commercial |
$368.56
|
| Rate for Payer: Anthem Medicaid |
$190.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$440.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cash Price |
$220.00
|
| Rate for Payer: Cigna Commercial |
$373.60
|
| Rate for Payer: Healthspan PPO |
$273.97
|
| Rate for Payer: Humana Medicaid |
$190.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$369.88
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$193.98
|
| Rate for Payer: Molina Healthcare Passport |
$190.18
|
| Rate for Payer: Multiplan PHCS |
$264.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$308.00
|
| Rate for Payer: UHCCP Medicaid |
$154.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.08
|
|
|
PED CRITICAL CARE INITIAL
|
Professional
|
Both
|
$980.00
|
|
|
Service Code
|
HCPCS 99471
|
| Hospital Charge Code |
51000313
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$343.00 |
| Max. Negotiated Rate |
$1,253.42 |
| Rate for Payer: Aetna Commercial |
$1,241.53
|
| Rate for Payer: Anthem Medicaid |
$636.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$980.00
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: Cigna Commercial |
$1,253.42
|
| Rate for Payer: Healthspan PPO |
$922.92
|
| Rate for Payer: Humana Medicaid |
$636.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,059.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$649.45
|
| Rate for Payer: Molina Healthcare Passport |
$636.72
|
| Rate for Payer: Multiplan PHCS |
$588.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$686.00
|
| Rate for Payer: UHCCP Medicaid |
$343.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$643.09
|
|
|
PEDIALYTE RTF GRAPE SOL 32OZ
|
Facility
|
OP
|
$4.91
|
|
|
Service Code
|
NDC 70074051753
|
| Hospital Charge Code |
25001167
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Aetna Commercial |
$72.13
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem Medicaid |
$32.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.07
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cash Price |
$46.84
|
| Rate for Payer: Cigna Commercial |
$77.75
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$89.00
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$79.63
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Humana KY Medicaid |
$32.22
|
| Rate for Payer: Kentucky WC Medicaid |
$32.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group HMO |
$70.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.04
|
| Rate for Payer: PHCS Commercial |
$89.93
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Payer |
$82.44
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
|
|
PEDIALYTE RTF GRAPE SOL 32OZ
|
Facility
|
IP
|
$4.91
|
|
|
Service Code
|
NDC 70074051753
|
| Hospital Charge Code |
25001167
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Aetna Commercial |
$72.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.07
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cash Price |
$46.84
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: Cigna Commercial |
$77.75
|
| Rate for Payer: First Health Commercial |
$89.00
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$79.63
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$69.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$82.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group HMO |
$70.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: PHCS Commercial |
$89.93
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$82.44
|
|
|
PEDIASURE
|
Facility
|
IP
|
$65.83
|
|
|
Service Code
|
NDC 70074051807
|
| Hospital Charge Code |
27000098
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$63.20 |
| Rate for Payer: Aetna Commercial |
$50.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.35
|
| Rate for Payer: Cash Price |
$32.92
|
| Rate for Payer: Cigna Commercial |
$54.64
|
| Rate for Payer: First Health Commercial |
$62.54
|
| Rate for Payer: Humana Commercial |
$55.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.93
|
| Rate for Payer: Ohio Health Group HMO |
$49.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.41
|
| Rate for Payer: PHCS Commercial |
$63.20
|
| Rate for Payer: United Healthcare All Payer |
$57.93
|
|
|
PEDIASURE
|
Facility
|
OP
|
$65.83
|
|
|
Service Code
|
NDC 70074051807
|
| Hospital Charge Code |
27000098
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$63.20 |
| Rate for Payer: Aetna Commercial |
$50.69
|
| Rate for Payer: Anthem Medicaid |
$22.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.35
|
| Rate for Payer: Cash Price |
$32.92
|
| Rate for Payer: Cigna Commercial |
$54.64
|
| Rate for Payer: First Health Commercial |
$62.54
|
| Rate for Payer: Humana Commercial |
$55.96
|
| Rate for Payer: Humana KY Medicaid |
$22.64
|
| Rate for Payer: Kentucky WC Medicaid |
$22.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.93
|
| Rate for Payer: Ohio Health Group HMO |
$49.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.41
|
| Rate for Payer: PHCS Commercial |
$63.20
|
| Rate for Payer: United Healthcare All Payer |
$57.93
|
|
|
PEDICLE E/N/E/L/NTRORAL
|
Facility
|
IP
|
$5,513.00
|
|
|
Service Code
|
HCPCS 15576
|
| Hospital Charge Code |
76100200
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$716.69 |
| Max. Negotiated Rate |
$5,292.48 |
| Rate for Payer: Aetna Commercial |
$4,245.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,300.14
|
| Rate for Payer: Cash Price |
$2,756.50
|
| Rate for Payer: Cigna Commercial |
$4,575.79
|
| Rate for Payer: First Health Commercial |
$5,237.35
|
| Rate for Payer: Humana Commercial |
$4,686.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,520.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,068.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,653.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,851.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,134.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,102.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$716.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,709.03
|
| Rate for Payer: PHCS Commercial |
$5,292.48
|
| Rate for Payer: United Healthcare All Payer |
$4,851.44
|
|
|
PEDICLE E/N/E/L/NTRORAL
|
Facility
|
OP
|
$5,513.00
|
|
|
Service Code
|
HCPCS 15576
|
| Hospital Charge Code |
76100200
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$716.69 |
| Max. Negotiated Rate |
$5,292.48 |
| Rate for Payer: Aetna Commercial |
$4,245.01
|
| Rate for Payer: Anthem Medicaid |
$1,895.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,300.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$2,756.50
|
| Rate for Payer: Cash Price |
$2,756.50
|
| Rate for Payer: Cigna Commercial |
$4,575.79
|
| Rate for Payer: First Health Commercial |
$5,237.35
|
| Rate for Payer: Humana Commercial |
$4,686.05
|
| Rate for Payer: Humana KY Medicaid |
$1,895.92
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,915.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,520.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,068.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,933.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,851.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,134.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,102.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$716.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,709.03
|
| Rate for Payer: PHCS Commercial |
$5,292.48
|
| Rate for Payer: United Healthcare All Payer |
$4,851.44
|
|
|
PEDICLE E/N/E/L/NTRORAL
|
Professional
|
Both
|
$5,513.00
|
|
|
Service Code
|
HCPCS 15576
|
| Hospital Charge Code |
76100200
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$223.56 |
| Max. Negotiated Rate |
$5,513.00 |
| Rate for Payer: Aetna Commercial |
$957.71
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$330.32
|
| Rate for Payer: Anthem Medicaid |
$223.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,513.00
|
| Rate for Payer: Cash Price |
$2,756.50
|
| Rate for Payer: Cash Price |
$2,756.50
|
| Rate for Payer: Cigna Commercial |
$1,016.13
|
| Rate for Payer: Healthspan PPO |
$894.58
|
| Rate for Payer: Humana Medicaid |
$223.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$843.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.03
|
| Rate for Payer: Molina Healthcare Passport |
$223.56
|
| Rate for Payer: Multiplan PHCS |
$3,307.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,859.10
|
| Rate for Payer: UHCCP Medicaid |
$346.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$225.80
|
|
|
PEDICLE E/N/E/L/NTRORAL(P
|
Professional
|
Both
|
$1,520.00
|
|
|
Service Code
|
HCPCS 15576
|
| Hospital Charge Code |
761P0200
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$223.56 |
| Max. Negotiated Rate |
$1,520.00 |
| Rate for Payer: Aetna Commercial |
$957.71
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$330.32
|
| Rate for Payer: Anthem Medicaid |
$223.56
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,520.00
|
| Rate for Payer: Cash Price |
$760.00
|
| Rate for Payer: Cash Price |
$760.00
|
| Rate for Payer: Cigna Commercial |
$1,016.13
|
| Rate for Payer: Healthspan PPO |
$894.58
|
| Rate for Payer: Humana Medicaid |
$223.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$843.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.03
|
| Rate for Payer: Molina Healthcare Passport |
$223.56
|
| Rate for Payer: Multiplan PHCS |
$912.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,064.00
|
| Rate for Payer: UHCCP Medicaid |
$346.84
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$225.80
|
|
|
PEDICLE E/N/E/L/NTRORAL(T
|
Facility
|
IP
|
$3,993.00
|
|
|
Service Code
|
HCPCS 15576
|
| Hospital Charge Code |
761T0200
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$519.09 |
| Max. Negotiated Rate |
$3,833.28 |
| Rate for Payer: Aetna Commercial |
$3,074.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,114.54
|
| Rate for Payer: Cash Price |
$1,996.50
|
| Rate for Payer: Cigna Commercial |
$3,314.19
|
| Rate for Payer: First Health Commercial |
$3,793.35
|
| Rate for Payer: Humana Commercial |
$3,394.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,274.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,946.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,197.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,513.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,994.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$798.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$519.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.83
|
| Rate for Payer: PHCS Commercial |
$3,833.28
|
| Rate for Payer: United Healthcare All Payer |
$3,513.84
|
|
|
PEDICLE E/N/E/L/NTRORAL(T
|
Facility
|
OP
|
$3,993.00
|
|
|
Service Code
|
HCPCS 15576
|
| Hospital Charge Code |
761T0200
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$519.09 |
| Max. Negotiated Rate |
$3,833.28 |
| Rate for Payer: Aetna Commercial |
$3,074.61
|
| Rate for Payer: Anthem Medicaid |
$1,373.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,114.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,996.50
|
| Rate for Payer: Cash Price |
$1,996.50
|
| Rate for Payer: Cigna Commercial |
$3,314.19
|
| Rate for Payer: First Health Commercial |
$3,793.35
|
| Rate for Payer: Humana Commercial |
$3,394.05
|
| Rate for Payer: Humana KY Medicaid |
$1,373.19
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,387.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,274.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,946.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,400.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,513.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,994.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$798.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$519.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,237.83
|
| Rate for Payer: PHCS Commercial |
$3,833.28
|
| Rate for Payer: United Healthcare All Payer |
$3,513.84
|
|
