|
APR-DRG 42.00: VIRAL MENINGITIS
|
Facility
|
IP
|
$4,222.29
|
|
|
Service Code
|
APR-DRG 0511
|
| Min. Negotiated Rate |
$4,222.29 |
| Max. Negotiated Rate |
$4,222.29 |
| Rate for Payer: Aetna CHP/Medicaid |
$4,222.29
|
| Rate for Payer: Humana OH Medicaid |
$4,222.29
|
|
|
APRESOLINE [20 MG] 20MG/1ML VL
|
Facility
|
IP
|
$121.32
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
25001872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$116.47 |
| Rate for Payer: Aetna Commercial |
$93.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.63
|
| Rate for Payer: Cash Price |
$60.66
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: First Health Commercial |
$115.25
|
| Rate for Payer: Humana Commercial |
$103.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.76
|
| Rate for Payer: Ohio Health Group HMO |
$90.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.71
|
| Rate for Payer: PHCS Commercial |
$116.47
|
| Rate for Payer: United Healthcare All Payer |
$106.76
|
|
|
APRESOLINE [20 MG] 20MG/1ML VL
|
Facility
|
OP
|
$121.32
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
25001872
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.40 |
| Max. Negotiated Rate |
$116.47 |
| Rate for Payer: Aetna Commercial |
$93.42
|
| Rate for Payer: Anthem Medicaid |
$41.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$94.63
|
| Rate for Payer: Cash Price |
$60.66
|
| Rate for Payer: Cigna Commercial |
$100.70
|
| Rate for Payer: First Health Commercial |
$115.25
|
| Rate for Payer: Humana Commercial |
$103.12
|
| Rate for Payer: Humana KY Medicaid |
$41.72
|
| Rate for Payer: Kentucky WC Medicaid |
$42.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.76
|
| Rate for Payer: Ohio Health Group HMO |
$90.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.71
|
| Rate for Payer: PHCS Commercial |
$116.47
|
| Rate for Payer: United Healthcare All Payer |
$106.76
|
|
|
APRESOLINE(HYDRALAZI 10MG/1TAB
|
Facility
|
OP
|
$4.43
|
|
|
Service Code
|
NDC 51079007420
|
| Hospital Charge Code |
25000242
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
APRESOLINE(HYDRALAZI 10MG/1TAB
|
Facility
|
IP
|
$4.43
|
|
|
Service Code
|
NDC 51079007420
|
| Hospital Charge Code |
25000242
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.25 |
| Rate for Payer: Aetna Commercial |
$3.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.68
|
| Rate for Payer: First Health Commercial |
$4.21
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.90
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.25
|
| Rate for Payer: United Healthcare All Payer |
$3.90
|
|
|
APRESOLINE(HYDRALAZI 25MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
25000243
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
APRESOLINE(HYDRALAZI 25MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 60687082201
|
| Hospital Charge Code |
25000243
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
APRETUDE 1mg (600mg SDV)
|
Facility
|
IP
|
$21,937.45
|
|
|
Service Code
|
HCPCS J0739
|
| Hospital Charge Code |
25004467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6,581.23 |
| Max. Negotiated Rate |
$21,059.95 |
| Rate for Payer: Aetna Commercial |
$16,891.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,111.21
|
| Rate for Payer: Cash Price |
$10,968.73
|
| Rate for Payer: Cigna Commercial |
$18,208.08
|
| Rate for Payer: First Health Commercial |
$20,840.58
|
| Rate for Payer: Humana Commercial |
$18,646.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,988.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,189.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,581.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,304.96
|
| Rate for Payer: Ohio Health Group HMO |
$16,453.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,549.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,085.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,136.84
|
| Rate for Payer: PHCS Commercial |
$21,059.95
|
| Rate for Payer: United Healthcare All Payer |
$19,304.96
|
|
|
APRETUDE 1mg (600mg SDV)
|
Facility
|
OP
|
$21,937.45
|
|
|
Service Code
|
HCPCS J0739
|
| Hospital Charge Code |
25004467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.03 |
| Max. Negotiated Rate |
$21,059.95 |
| Rate for Payer: Aetna Commercial |
$16,891.84
|
| Rate for Payer: Anthem Medicaid |
$7,544.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,111.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.49
|
| Rate for Payer: Cash Price |
$10,968.73
|
| Rate for Payer: Cash Price |
$10,968.73
|
| Rate for Payer: Cigna Commercial |
$18,208.08
|
| Rate for Payer: First Health Commercial |
$20,840.58
|
| Rate for Payer: Humana Commercial |
$18,646.83
|
| Rate for Payer: Humana KY Medicaid |
$7,544.29
|
| Rate for Payer: Humana Medicare Advantage |
$7.03
|
| Rate for Payer: Kentucky WC Medicaid |
$7,621.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,988.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,189.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,695.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,304.96
|
| Rate for Payer: Ohio Health Group HMO |
$16,453.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,549.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,085.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,136.84
|
| Rate for Payer: PHCS Commercial |
$21,059.95
|
| Rate for Payer: United Healthcare All Payer |
$19,304.96
|
|
|
APRISO 0.375GM CAPSULE
|
Facility
|
IP
|
$12.25
|
|
|
Service Code
|
NDC 65649010302
|
| Hospital Charge Code |
25000244
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Aetna Commercial |
$9.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.55
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna Commercial |
$10.17
|
| Rate for Payer: First Health Commercial |
$11.64
|
| Rate for Payer: Humana Commercial |
$10.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.78
|
| Rate for Payer: Ohio Health Group HMO |
$9.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.45
|
| Rate for Payer: PHCS Commercial |
$11.76
|
| Rate for Payer: United Healthcare All Payer |
$10.78
|
|
|
APRISO 0.375GM CAPSULE
|
Facility
|
OP
|
$12.25
|
|
|
Service Code
|
NDC 65649010302
|
| Hospital Charge Code |
25000244
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$11.76 |
| Rate for Payer: Aetna Commercial |
$9.43
|
| Rate for Payer: Anthem Medicaid |
$4.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.55
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna Commercial |
$10.17
|
| Rate for Payer: First Health Commercial |
$11.64
|
| Rate for Payer: Humana Commercial |
$10.41
|
| Rate for Payer: Humana KY Medicaid |
$4.21
|
| Rate for Payer: Kentucky WC Medicaid |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.78
|
| Rate for Payer: Ohio Health Group HMO |
$9.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.45
|
| Rate for Payer: PHCS Commercial |
$11.76
|
| Rate for Payer: United Healthcare All Payer |
$10.78
|
|
|
AP SHOULDER LT 1 VIEW
|
Professional
|
Both
|
$327.00
|
|
|
Service Code
|
HCPCS 73020
|
| Hospital Charge Code |
32000074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$196.20 |
| Rate for Payer: Aetna Commercial |
$35.41
|
| Rate for Payer: Ambetter Exchange |
$19.66
|
| Rate for Payer: Anthem Medicaid |
$19.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$19.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$19.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.59
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$36.96
|
| Rate for Payer: Healthspan PPO |
$33.18
|
| Rate for Payer: Humana Medicaid |
$19.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$9.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$19.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.71
|
| Rate for Payer: Molina Healthcare Passport |
$19.32
|
| Rate for Payer: Multiplan PHCS |
$196.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.56
|
| Rate for Payer: UHCCP Medicaid |
$114.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$19.66
|
|
|
AP SHOULDER LT 1 VIEW
|
Facility
|
IP
|
$327.00
|
|
|
Service Code
|
HCPCS 73020
|
| Hospital Charge Code |
32000074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$98.10 |
| Max. Negotiated Rate |
$313.92 |
| Rate for Payer: Aetna Commercial |
$251.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.06
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$271.41
|
| Rate for Payer: First Health Commercial |
$310.65
|
| Rate for Payer: Humana Commercial |
$277.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.76
|
| Rate for Payer: Ohio Health Group HMO |
$245.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.63
|
| Rate for Payer: PHCS Commercial |
$313.92
|
| Rate for Payer: United Healthcare All Payer |
$287.76
|
|
|
AP SHOULDER LT 1 VIEW
|
Facility
|
OP
|
$327.00
|
|
|
Service Code
|
HCPCS 73020
|
| Hospital Charge Code |
32000074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$313.92 |
| Rate for Payer: Aetna Commercial |
$251.79
|
| Rate for Payer: Anthem Medicaid |
$112.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$255.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cash Price |
$163.50
|
| Rate for Payer: Cigna Commercial |
$271.41
|
| Rate for Payer: First Health Commercial |
$310.65
|
| Rate for Payer: Humana Commercial |
$277.95
|
| Rate for Payer: Humana KY Medicaid |
$112.46
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$113.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$268.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$241.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$114.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$287.76
|
| Rate for Payer: Ohio Health Group HMO |
$245.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$284.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.63
|
| Rate for Payer: PHCS Commercial |
$313.92
|
| Rate for Payer: United Healthcare All Payer |
$287.76
|
|
|
AP SHOULDER LT 1 VIEW(P
|
Professional
|
Both
|
$50.00
|
|
|
Service Code
|
HCPCS 73020
|
| Hospital Charge Code |
320P0074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$9.53 |
| Max. Negotiated Rate |
$36.96 |
| Rate for Payer: Aetna Commercial |
$35.41
|
| Rate for Payer: Ambetter Exchange |
$19.66
|
| Rate for Payer: Anthem Medicaid |
$19.32
|
| Rate for Payer: Buckeye Individual/Medicaid |
$19.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$19.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.59
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cash Price |
$25.00
|
| Rate for Payer: Cigna Commercial |
$36.96
|
| Rate for Payer: Healthspan PPO |
$33.18
|
| Rate for Payer: Humana Medicaid |
$19.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$9.53
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$19.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.71
|
| Rate for Payer: Molina Healthcare Passport |
$19.32
|
| Rate for Payer: Multiplan PHCS |
$30.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$25.56
|
| Rate for Payer: UHCCP Medicaid |
$17.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$19.66
|
|
|
AP SHOULDER LT 1 VIEW(T
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 73020
|
| Hospital Charge Code |
320T0074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$265.92 |
| Rate for Payer: Aetna Commercial |
$213.29
|
| Rate for Payer: Anthem Medicaid |
$95.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$229.91
|
| Rate for Payer: First Health Commercial |
$263.15
|
| Rate for Payer: Humana Commercial |
$235.45
|
| Rate for Payer: Humana KY Medicaid |
$95.26
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$96.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$204.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$243.76
|
| Rate for Payer: Ohio Health Group HMO |
$207.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$221.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.13
|
| Rate for Payer: PHCS Commercial |
$265.92
|
| Rate for Payer: United Healthcare All Payer |
$243.76
|
|
|
AP SHOULDER LT 1 VIEW(T
|
Facility
|
IP
|
$277.00
|
|
|
Service Code
|
HCPCS 73020
|
| Hospital Charge Code |
320T0074
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.10 |
| Max. Negotiated Rate |
$265.92 |
| Rate for Payer: Aetna Commercial |
$213.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$216.06
|
| Rate for Payer: Cash Price |
$138.50
|
| Rate for Payer: Cigna Commercial |
$229.91
|
| Rate for Payer: First Health Commercial |
$263.15
|
| Rate for Payer: Humana Commercial |
$235.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$227.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$204.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$83.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$243.76
|
| Rate for Payer: Ohio Health Group HMO |
$207.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$221.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$191.13
|
| Rate for Payer: PHCS Commercial |
$265.92
|
| Rate for Payer: United Healthcare All Payer |
$243.76
|
|
|
AP SKSB T/A/L<1001ST 25SCM LC
|
Professional
|
Both
|
$3,852.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
76100190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$2,311.20 |
| Rate for Payer: Ambetter Exchange |
$79.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.75
|
| Rate for Payer: Anthem Medicaid |
$113.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.29
|
| Rate for Payer: Cash Price |
$1,926.00
|
| Rate for Payer: Cash Price |
$1,926.00
|
| Rate for Payer: Cigna Commercial |
$148.63
|
| Rate for Payer: Healthspan PPO |
$129.96
|
| Rate for Payer: Humana Medicaid |
$113.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.40
|
| Rate for Payer: Molina Healthcare Passport |
$113.14
|
| Rate for Payer: Multiplan PHCS |
$2,311.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.23
|
| Rate for Payer: UHCCP Medicaid |
$45.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$114.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.41
|
|
|
AP SKSB T/A/L<1001ST 25SCM LC
|
Facility
|
IP
|
$3,852.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
76100190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,155.60 |
| Max. Negotiated Rate |
$3,697.92 |
| Rate for Payer: Aetna Commercial |
$2,966.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,004.56
|
| Rate for Payer: Cash Price |
$1,926.00
|
| Rate for Payer: Cigna Commercial |
$3,197.16
|
| Rate for Payer: First Health Commercial |
$3,659.40
|
| Rate for Payer: Humana Commercial |
$3,274.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,158.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,842.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,389.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,889.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,351.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,657.88
|
| Rate for Payer: PHCS Commercial |
$3,697.92
|
| Rate for Payer: United Healthcare All Payer |
$3,389.76
|
|
|
AP SKSB T/A/L<1001ST 25SCM LC
|
Facility
|
OP
|
$3,852.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
76100190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,324.70 |
| Max. Negotiated Rate |
$3,697.92 |
| Rate for Payer: Aetna Commercial |
$2,966.04
|
| Rate for Payer: Anthem Medicaid |
$1,324.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,004.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,926.00
|
| Rate for Payer: Cash Price |
$1,926.00
|
| Rate for Payer: Cigna Commercial |
$3,197.16
|
| Rate for Payer: First Health Commercial |
$3,659.40
|
| Rate for Payer: Humana Commercial |
$3,274.20
|
| Rate for Payer: Humana KY Medicaid |
$1,324.70
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,338.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,158.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,842.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,351.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,389.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,889.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,081.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,351.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,657.88
|
| Rate for Payer: PHCS Commercial |
$3,697.92
|
| Rate for Payer: United Healthcare All Payer |
$3,389.76
|
|
|
AP SKSB T/A/L<1001ST 25SCM L(P
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
761P0190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.75 |
| Max. Negotiated Rate |
$285.00 |
| Rate for Payer: Ambetter Exchange |
$79.41
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$43.75
|
| Rate for Payer: Anthem Medicaid |
$113.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$79.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$79.41
|
| Rate for Payer: CareSource Just4Me Medicare |
$95.29
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$148.63
|
| Rate for Payer: Healthspan PPO |
$129.96
|
| Rate for Payer: Humana Medicaid |
$113.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.56
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$79.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.41
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$115.40
|
| Rate for Payer: Molina Healthcare Passport |
$113.14
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.23
|
| Rate for Payer: UHCCP Medicaid |
$45.94
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$114.27
|
| Rate for Payer: Wellcare Medicare Advantage |
$79.41
|
|
|
AP SKSB T/A/L<1001ST 25SCM L(T
|
Facility
|
IP
|
$3,377.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
761T0190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,013.10 |
| Max. Negotiated Rate |
$3,241.92 |
| Rate for Payer: Aetna Commercial |
$2,600.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,634.06
|
| Rate for Payer: Cash Price |
$1,688.50
|
| Rate for Payer: Cigna Commercial |
$2,802.91
|
| Rate for Payer: First Health Commercial |
$3,208.15
|
| Rate for Payer: Humana Commercial |
$2,870.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,769.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,492.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,013.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,971.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,532.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,701.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,937.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,330.13
|
| Rate for Payer: PHCS Commercial |
$3,241.92
|
| Rate for Payer: United Healthcare All Payer |
$2,971.76
|
|
|
AP SKSB T/A/L<1001ST 25SCM L(T
|
Facility
|
OP
|
$3,377.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
761T0190
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,161.35 |
| Max. Negotiated Rate |
$3,241.92 |
| Rate for Payer: Aetna Commercial |
$2,600.29
|
| Rate for Payer: Anthem Medicaid |
$1,161.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,634.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$1,688.50
|
| Rate for Payer: Cash Price |
$1,688.50
|
| Rate for Payer: Cigna Commercial |
$2,802.91
|
| Rate for Payer: First Health Commercial |
$3,208.15
|
| Rate for Payer: Humana Commercial |
$2,870.45
|
| Rate for Payer: Humana KY Medicaid |
$1,161.35
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,173.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,769.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,492.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,184.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,971.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,532.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,701.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,937.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,330.13
|
| Rate for Payer: PHCS Commercial |
$3,241.92
|
| Rate for Payer: United Healthcare All Payer |
$2,971.76
|
|
|
AP SKSB T/A/L ADTL25CM HC
|
Facility
|
IP
|
$433.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
76100191
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.90 |
| Max. Negotiated Rate |
$415.68 |
| Rate for Payer: Aetna Commercial |
$333.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.74
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Cigna Commercial |
$359.39
|
| Rate for Payer: First Health Commercial |
$411.35
|
| Rate for Payer: Humana Commercial |
$368.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$355.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$319.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$381.04
|
| Rate for Payer: Ohio Health Group HMO |
$324.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$346.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.77
|
| Rate for Payer: PHCS Commercial |
$415.68
|
| Rate for Payer: United Healthcare All Payer |
$381.04
|
|
|
AP SKSB T/A/L ADTL25CM HC
|
Facility
|
OP
|
$433.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
76100191
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.90 |
| Max. Negotiated Rate |
$415.68 |
| Rate for Payer: Aetna Commercial |
$333.41
|
| Rate for Payer: Anthem Medicaid |
$148.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.74
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Cigna Commercial |
$359.39
|
| Rate for Payer: First Health Commercial |
$411.35
|
| Rate for Payer: Humana Commercial |
$368.05
|
| Rate for Payer: Humana KY Medicaid |
$148.91
|
| Rate for Payer: Kentucky WC Medicaid |
$150.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$355.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$319.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$151.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$381.04
|
| Rate for Payer: Ohio Health Group HMO |
$324.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$346.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.77
|
| Rate for Payer: PHCS Commercial |
$415.68
|
| Rate for Payer: United Healthcare All Payer |
$381.04
|
|
