|
ATROVENT (IPRATROPIUM) 2.5ML
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 60687039479
|
| Hospital Charge Code |
25000281
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
ATROVENT (IPRATROPIUM) 2.5ML
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 60687039479
|
| Hospital Charge Code |
25000281
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
| Rate for Payer: Aetna Commercial |
$3.46
|
|
|
ATROVENT (IPROTROPIUM) NA 30ML
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 54004544
|
| Hospital Charge Code |
25000283
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna Commercial |
$0.42
|
| Rate for Payer: Anthem Medicaid |
$0.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna Commercial |
$0.45
|
| Rate for Payer: First Health Commercial |
$0.51
|
| Rate for Payer: Humana Commercial |
$0.46
|
| Rate for Payer: Humana KY Medicaid |
$0.19
|
| Rate for Payer: Kentucky WC Medicaid |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.48
|
| Rate for Payer: Ohio Health Group HMO |
$0.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.17
|
| Rate for Payer: PHCS Commercial |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.48
|
|
|
ATROVENT (IPROTROPIUM) NA 30ML
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 54004544
|
| Hospital Charge Code |
25000283
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna Commercial |
$0.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna Commercial |
$0.45
|
| Rate for Payer: First Health Commercial |
$0.51
|
| Rate for Payer: Humana Commercial |
$0.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.48
|
| Rate for Payer: Ohio Health Group HMO |
$0.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.17
|
| Rate for Payer: PHCS Commercial |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.48
|
|
|
ATTAIN COMMAND CATH 6250V-45S
|
Facility
|
OP
|
$1,962.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.12 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$1,511.12
|
| Rate for Payer: Anthem Medicaid |
$674.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.75
|
| Rate for Payer: Cash Price |
$981.25
|
| Rate for Payer: Cigna Commercial |
$1,628.88
|
| Rate for Payer: First Health Commercial |
$1,864.38
|
| Rate for Payer: Humana Commercial |
$1,668.12
|
| Rate for Payer: Humana KY Medicaid |
$674.90
|
| Rate for Payer: Kentucky WC Medicaid |
$681.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,609.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$688.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,727.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$608.38
|
| Rate for Payer: PHCS Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare All Payer |
$1,727.00
|
|
|
ATTAIN COMMAND CATH 6250V-45S
|
Facility
|
IP
|
$1,962.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.12 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$1,511.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.75
|
| Rate for Payer: Cash Price |
$981.25
|
| Rate for Payer: Cigna Commercial |
$1,628.88
|
| Rate for Payer: First Health Commercial |
$1,864.38
|
| Rate for Payer: Humana Commercial |
$1,668.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,609.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,727.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$608.38
|
| Rate for Payer: PHCS Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare All Payer |
$1,727.00
|
|
|
ATTAIN COMMAND CATH 6250V-50S
|
Facility
|
OP
|
$1,962.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.12 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$1,511.12
|
| Rate for Payer: Anthem Medicaid |
$674.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.75
|
| Rate for Payer: Cash Price |
$981.25
|
| Rate for Payer: Cigna Commercial |
$1,628.88
|
| Rate for Payer: First Health Commercial |
$1,864.38
|
| Rate for Payer: Humana Commercial |
$1,668.12
|
| Rate for Payer: Humana KY Medicaid |
$674.90
|
| Rate for Payer: Kentucky WC Medicaid |
$681.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,609.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$688.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,727.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$608.38
|
| Rate for Payer: PHCS Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare All Payer |
$1,727.00
|
|
|
ATTAIN COMMAND CATH 6250V-50S
|
Facility
|
IP
|
$1,962.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.12 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$1,511.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.75
|
| Rate for Payer: Cash Price |
$981.25
|
| Rate for Payer: Cigna Commercial |
$1,628.88
|
| Rate for Payer: First Health Commercial |
$1,864.38
|
| Rate for Payer: Humana Commercial |
$1,668.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,609.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,727.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$608.38
|
| Rate for Payer: PHCS Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare All Payer |
$1,727.00
|
|
|
ATTAIN COMMAND CATH 6250V-EH
|
Facility
|
OP
|
$2,092.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.96 |
| Max. Negotiated Rate |
$2,008.32 |
| Rate for Payer: Aetna Commercial |
$1,610.84
|
| Rate for Payer: Anthem Medicaid |
$719.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,631.76
|
| Rate for Payer: Cash Price |
$1,046.00
|
| Rate for Payer: Cigna Commercial |
$1,736.36
|
| Rate for Payer: First Health Commercial |
$1,987.40
|
| Rate for Payer: Humana Commercial |
$1,778.20
|
| Rate for Payer: Humana KY Medicaid |
$719.44
|
| Rate for Payer: Kentucky WC Medicaid |
$726.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,715.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,543.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$733.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,840.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,569.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$418.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$648.52
|
| Rate for Payer: PHCS Commercial |
$2,008.32
|
| Rate for Payer: United Healthcare All Payer |
$1,840.96
|
|
|
ATTAIN COMMAND CATH 6250V-EH
|
Facility
|
IP
|
$2,092.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.96 |
| Max. Negotiated Rate |
$2,008.32 |
| Rate for Payer: Aetna Commercial |
$1,610.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,631.76
|
| Rate for Payer: Cash Price |
$1,046.00
|
| Rate for Payer: Cigna Commercial |
$1,736.36
|
| Rate for Payer: First Health Commercial |
$1,987.40
|
| Rate for Payer: Humana Commercial |
$1,778.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,715.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,543.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$627.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,840.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,569.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$418.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$648.52
|
| Rate for Payer: PHCS Commercial |
$2,008.32
|
| Rate for Payer: United Healthcare All Payer |
$1,840.96
|
|
|
ATTENDANCE AT DELIVERY
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
HCPCS 99464
|
| Hospital Charge Code |
51000120
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.26 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$112.28
|
| Rate for Payer: Anthem Medicaid |
$57.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$360.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$114.01
|
| Rate for Payer: Healthspan PPO |
$83.47
|
| Rate for Payer: Humana Medicaid |
$57.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$97.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.41
|
| Rate for Payer: Molina Healthcare Passport |
$57.26
|
| Rate for Payer: Multiplan PHCS |
$216.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$252.00
|
| Rate for Payer: UHCCP Medicaid |
$126.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.83
|
|
|
ATTENDANCE AT DELIVERY
|
Facility
|
IP
|
$360.00
|
|
|
Service Code
|
HCPCS 99464
|
| Hospital Charge Code |
51000120
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$345.60 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$280.80
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$298.80
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: Humana Commercial |
$306.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$295.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$265.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$316.80
|
| Rate for Payer: Ohio Health Group HMO |
$270.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$111.60
|
| Rate for Payer: PHCS Commercial |
$345.60
|
| Rate for Payer: United Healthcare All Payer |
$316.80
|
|
|
ATTENDANCE AT DELIVERY
|
Facility
|
OP
|
$360.00
|
|
|
Service Code
|
HCPCS 99464
|
| Hospital Charge Code |
51000120
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$345.60 |
| Rate for Payer: Aetna Commercial |
$277.20
|
| Rate for Payer: Anthem Medicaid |
$123.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$280.80
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$298.80
|
| Rate for Payer: First Health Commercial |
$342.00
|
| Rate for Payer: Humana Commercial |
$306.00
|
| Rate for Payer: Humana KY Medicaid |
$123.80
|
| Rate for Payer: Kentucky WC Medicaid |
$125.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$295.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$265.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$108.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$126.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$316.80
|
| Rate for Payer: Ohio Health Group HMO |
$270.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$46.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$111.60
|
| Rate for Payer: PHCS Commercial |
$345.60
|
| Rate for Payer: United Healthcare All Payer |
$316.80
|
|
|
ATTENDANCE AT DELIVERY(P
|
Professional
|
Both
|
$360.00
|
|
|
Service Code
|
HCPCS 99464
|
| Hospital Charge Code |
510P0120
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$57.26 |
| Max. Negotiated Rate |
$360.00 |
| Rate for Payer: Aetna Commercial |
$112.28
|
| Rate for Payer: Anthem Medicaid |
$57.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$360.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cash Price |
$180.00
|
| Rate for Payer: Cigna Commercial |
$114.01
|
| Rate for Payer: Healthspan PPO |
$83.47
|
| Rate for Payer: Humana Medicaid |
$57.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$97.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$58.41
|
| Rate for Payer: Molina Healthcare Passport |
$57.26
|
| Rate for Payer: Multiplan PHCS |
$216.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$252.00
|
| Rate for Payer: UHCCP Medicaid |
$126.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$57.83
|
|
|
AUDIT/DAST 15-30 MIN
|
Professional
|
Both
|
$148.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
51000110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$148.00 |
| Rate for Payer: Aetna Commercial |
$50.01
|
| Rate for Payer: Anthem Medicaid |
$20.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$148.00
|
| Rate for Payer: Cash Price |
$74.00
|
| Rate for Payer: Cash Price |
$74.00
|
| Rate for Payer: Cigna Commercial |
$44.70
|
| Rate for Payer: Healthspan PPO |
$40.72
|
| Rate for Payer: Humana Medicaid |
$20.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.40
|
| Rate for Payer: Molina Healthcare Passport |
$20.00
|
| Rate for Payer: Multiplan PHCS |
$88.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$103.60
|
| Rate for Payer: UHCCP Medicaid |
$51.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.20
|
|
|
AUDIT/DAST 15-30 MIN
|
Facility
|
OP
|
$148.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
51000110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$142.08 |
| Rate for Payer: Aetna Commercial |
$113.96
|
| Rate for Payer: Anthem Medicaid |
$50.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.44
|
| Rate for Payer: Cash Price |
$74.00
|
| Rate for Payer: Cigna Commercial |
$122.84
|
| Rate for Payer: First Health Commercial |
$140.60
|
| Rate for Payer: Humana Commercial |
$125.80
|
| Rate for Payer: Humana KY Medicaid |
$50.90
|
| Rate for Payer: Kentucky WC Medicaid |
$51.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$51.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.24
|
| Rate for Payer: Ohio Health Group HMO |
$111.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.88
|
| Rate for Payer: PHCS Commercial |
$142.08
|
| Rate for Payer: United Healthcare All Payer |
$130.24
|
|
|
AUDIT/DAST 15-30 MIN
|
Facility
|
IP
|
$148.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
51000110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$142.08 |
| Rate for Payer: Aetna Commercial |
$113.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.44
|
| Rate for Payer: Cash Price |
$74.00
|
| Rate for Payer: Cigna Commercial |
$122.84
|
| Rate for Payer: First Health Commercial |
$140.60
|
| Rate for Payer: Humana Commercial |
$125.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.24
|
| Rate for Payer: Ohio Health Group HMO |
$111.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.88
|
| Rate for Payer: PHCS Commercial |
$142.08
|
| Rate for Payer: United Healthcare All Payer |
$130.24
|
|
|
AUDIT/DAST 15-30 MIN(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
510P0110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$50.01
|
| Rate for Payer: Anthem Medicaid |
$20.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$44.70
|
| Rate for Payer: Healthspan PPO |
$40.72
|
| Rate for Payer: Humana Medicaid |
$20.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$45.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$20.40
|
| Rate for Payer: Molina Healthcare Passport |
$20.00
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$20.20
|
|
|
AUDIT/DAST 15-30 MIN(T
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
510T0110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$46.08 |
| Rate for Payer: Aetna Commercial |
$36.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.44
|
| 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
|
|
|
AUDIT/DAST 15-30 MIN(T
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
HCPCS 99408
|
| Hospital Charge Code |
510T0110
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$46.08 |
| Rate for Payer: Aetna Commercial |
$36.96
|
| Rate for Payer: Anthem Medicaid |
$16.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$37.44
|
| 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 |
$16.51
|
| Rate for Payer: Kentucky WC Medicaid |
$16.68
|
| 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: Molina Healthcare Medicaid |
$16.84
|
| 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
|
|
|
AUDIT/DAST OVER 30 MIN
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
51000111
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.60 |
| Rate for Payer: Aetna Commercial |
$123.20
|
| Rate for Payer: Anthem Medicaid |
$55.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.80
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: First Health Commercial |
$152.00
|
| Rate for Payer: Humana Commercial |
$136.00
|
| Rate for Payer: Humana KY Medicaid |
$55.02
|
| Rate for Payer: Kentucky WC Medicaid |
$55.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$56.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.80
|
| Rate for Payer: Ohio Health Group HMO |
$120.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.60
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
AUDIT/DAST OVER 30 MIN
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
51000111
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: Aetna Commercial |
$100.74
|
| Rate for Payer: Anthem Medicaid |
$53.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$87.77
|
| Rate for Payer: Healthspan PPO |
$80.34
|
| Rate for Payer: Humana Medicaid |
$53.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.26
|
| Rate for Payer: Molina Healthcare Passport |
$53.20
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.73
|
|
|
AUDIT/DAST OVER 30 MIN
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
51000111
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.60 |
| Rate for Payer: Aetna Commercial |
$123.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.80
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: First Health Commercial |
$152.00
|
| Rate for Payer: Humana Commercial |
$136.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.80
|
| Rate for Payer: Ohio Health Group HMO |
$120.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.60
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
AUDIT/DAST OVER 30 MIN(P
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS 99409
|
| Hospital Charge Code |
510P0111
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: Aetna Commercial |
$100.74
|
| Rate for Payer: Anthem Medicaid |
$53.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$160.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$87.77
|
| Rate for Payer: Healthspan PPO |
$80.34
|
| Rate for Payer: Humana Medicaid |
$53.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$89.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$54.26
|
| Rate for Payer: Molina Healthcare Passport |
$53.20
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.73
|
|
|
AUGMENT 25062.5MG/5ML EQ100ML
|
Facility
|
IP
|
$11.46
|
|
|
Service Code
|
NDC 60432006500
|
| Hospital Charge Code |
25002861
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna Commercial |
$8.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.94
|
| Rate for Payer: Cash Price |
$5.73
|
| Rate for Payer: Cigna Commercial |
$9.51
|
| Rate for Payer: First Health Commercial |
$10.89
|
| Rate for Payer: Humana Commercial |
$9.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.08
|
| Rate for Payer: Ohio Health Group HMO |
$8.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.55
|
| Rate for Payer: PHCS Commercial |
$11.00
|
| Rate for Payer: United Healthcare All Payer |
$10.08
|
|
