|
PREMARIN(CONJ ESTR 1.25MG/1TAB
|
Facility
|
OP
|
$23.91
|
|
|
Service Code
|
NDC 46110481
|
| Hospital Charge Code |
25003817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem Medicaid |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Humana KY Medicaid |
$8.22
|
| Rate for Payer: Kentucky WC Medicaid |
$8.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMARIN(CONJ ESTR 1.25MG/1TAB
|
Facility
|
IP
|
$23.91
|
|
|
Service Code
|
NDC 46110481
|
| Hospital Charge Code |
25003817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMARIN(CONJ ESTR .625MG/1TAB
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 66267017430
|
| Hospital Charge Code |
25003815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
PREMARIN(CONJ ESTR .625MG/1TAB
|
Facility
|
IP
|
$9.11
|
|
|
Service Code
|
NDC 66267017430
|
| Hospital Charge Code |
25003815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.75 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.11
|
| Rate for Payer: Cash Price |
$4.56
|
| Rate for Payer: Cigna Commercial |
$7.56
|
| Rate for Payer: First Health Commercial |
$8.65
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.02
|
| Rate for Payer: Ohio Health Group HMO |
$6.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
PREMARIN(CONJ ESTRO .9MG/1TAB
|
Facility
|
IP
|
$23.91
|
|
|
Service Code
|
NDC 46110381
|
| Hospital Charge Code |
25003816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMARIN(CONJ ESTRO .9MG/1TAB
|
Facility
|
OP
|
$23.91
|
|
|
Service Code
|
NDC 46110381
|
| Hospital Charge Code |
25003816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem Medicaid |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Humana KY Medicaid |
$8.22
|
| Rate for Payer: Kentucky WC Medicaid |
$8.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMARIN(CONJ ESTROG .3MG/1TAB
|
Facility
|
OP
|
$23.91
|
|
|
Service Code
|
NDC 46110081
|
| Hospital Charge Code |
25001216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem Medicaid |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Humana KY Medicaid |
$8.22
|
| Rate for Payer: Kentucky WC Medicaid |
$8.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMARIN(CONJ ESTROG .3MG/1TAB
|
Facility
|
IP
|
$23.91
|
|
|
Service Code
|
NDC 46110081
|
| Hospital Charge Code |
25001216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
|
|
PREMARIN(CONJ ESTROGE 25MG/5ML
|
Facility
|
IP
|
$948.05
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
25002055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.25 |
| Max. Negotiated Rate |
$910.13 |
| Rate for Payer: Aetna Commercial |
$730.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.48
|
| Rate for Payer: Cash Price |
$474.02
|
| Rate for Payer: Cigna Commercial |
$786.88
|
| Rate for Payer: First Health Commercial |
$900.65
|
| Rate for Payer: Humana Commercial |
$805.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.28
|
| Rate for Payer: Ohio Health Group HMO |
$711.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.90
|
| Rate for Payer: PHCS Commercial |
$910.13
|
| Rate for Payer: United Healthcare All Payer |
$834.28
|
|
|
PREMARIN(CONJ ESTROGE 25MG/5ML
|
Facility
|
OP
|
$948.05
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
25002055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$123.25 |
| Max. Negotiated Rate |
$910.13 |
| Rate for Payer: Aetna Commercial |
$730.00
|
| Rate for Payer: Anthem Medicaid |
$326.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$372.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$521.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$502.40
|
| Rate for Payer: Cash Price |
$474.02
|
| Rate for Payer: Cash Price |
$474.02
|
| Rate for Payer: Cigna Commercial |
$786.88
|
| Rate for Payer: First Health Commercial |
$900.65
|
| Rate for Payer: Humana Commercial |
$805.84
|
| Rate for Payer: Humana KY Medicaid |
$326.03
|
| Rate for Payer: Humana Medicare Advantage |
$372.15
|
| Rate for Payer: Kentucky WC Medicaid |
$329.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$446.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.28
|
| Rate for Payer: Ohio Health Group HMO |
$711.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.90
|
| Rate for Payer: PHCS Commercial |
$910.13
|
| Rate for Payer: United Healthcare All Payer |
$834.28
|
|
|
PREMARIN (CONJ ESTROGEN 42.5GM
|
Facility
|
IP
|
$35.17
|
|
|
Service Code
|
NDC 46087221
|
| Hospital Charge Code |
25001214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$33.76 |
| Rate for Payer: Aetna Commercial |
$27.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.43
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cigna Commercial |
$29.19
|
| Rate for Payer: First Health Commercial |
$33.41
|
| Rate for Payer: Humana Commercial |
$29.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.95
|
| Rate for Payer: Ohio Health Group HMO |
$26.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.90
|
| Rate for Payer: PHCS Commercial |
$33.76
|
| Rate for Payer: United Healthcare All Payer |
$30.95
|
|
|
PREMARIN (CONJ ESTROGEN 42.5GM
|
Facility
|
OP
|
$35.17
|
|
|
Service Code
|
NDC 46087221
|
| Hospital Charge Code |
25001214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$33.76 |
| Rate for Payer: Aetna Commercial |
$27.08
|
| Rate for Payer: Anthem Medicaid |
$12.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.43
|
| Rate for Payer: Cash Price |
$17.59
|
| Rate for Payer: Cigna Commercial |
$29.19
|
| Rate for Payer: First Health Commercial |
$33.41
|
| Rate for Payer: Humana Commercial |
$29.89
|
| Rate for Payer: Humana KY Medicaid |
$12.09
|
| Rate for Payer: Kentucky WC Medicaid |
$12.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.95
|
| Rate for Payer: Ohio Health Group HMO |
$26.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.90
|
| Rate for Payer: PHCS Commercial |
$33.76
|
| Rate for Payer: United Healthcare All Payer |
$30.95
|
|
|
PREMARIN(ESTROGENS) 0.45MG TAB
|
Facility
|
IP
|
$23.91
|
|
|
Service Code
|
NDC 46110181
|
| Hospital Charge Code |
25001217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMARIN(ESTROGENS) 0.45MG TAB
|
Facility
|
OP
|
$23.91
|
|
|
Service Code
|
NDC 46110181
|
| Hospital Charge Code |
25001217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$22.95 |
| Rate for Payer: Aetna Commercial |
$18.41
|
| Rate for Payer: Anthem Medicaid |
$8.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.65
|
| Rate for Payer: Cash Price |
$11.96
|
| Rate for Payer: Cigna Commercial |
$19.85
|
| Rate for Payer: First Health Commercial |
$22.71
|
| Rate for Payer: Humana Commercial |
$20.32
|
| Rate for Payer: Humana KY Medicaid |
$8.22
|
| Rate for Payer: Kentucky WC Medicaid |
$8.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.04
|
| Rate for Payer: Ohio Health Group HMO |
$17.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.41
|
| Rate for Payer: PHCS Commercial |
$22.95
|
| Rate for Payer: United Healthcare All Payer |
$21.04
|
|
|
PREMATURITY WITH MAJOR PROBLEMS
|
Facility
|
IP
|
$47,935.73
|
|
|
Service Code
|
MSDRG 791
|
| Min. Negotiated Rate |
$32,527.82 |
| Max. Negotiated Rate |
$47,935.73 |
| Rate for Payer: Anthem Medicaid |
$32,527.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34,239.81
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$47,935.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$46,223.74
|
| Rate for Payer: Humana KY Medicaid |
$32,527.82
|
| Rate for Payer: Humana Medicare Advantage |
$34,239.81
|
| Rate for Payer: Kentucky WC Medicaid |
$32,853.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41,087.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$33,178.38
|
|
|
PREMATURITY WITHOUT MAJOR PROBLEMS
|
Facility
|
IP
|
$28,923.80
|
|
|
Service Code
|
MSDRG 792
|
| Min. Negotiated Rate |
$19,626.87 |
| Max. Negotiated Rate |
$28,923.80 |
| Rate for Payer: Anthem Medicaid |
$19,626.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20,659.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28,923.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$27,890.81
|
| Rate for Payer: Humana KY Medicaid |
$19,626.87
|
| Rate for Payer: Humana Medicare Advantage |
$20,659.86
|
| Rate for Payer: Kentucky WC Medicaid |
$19,823.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,791.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$20,019.40
|
|
|
PREPARATION H (57GM)
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 536128806
|
| Hospital Charge Code |
25004113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
PREPARATION H (57GM)
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 536128806
|
| Hospital Charge Code |
25004113
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
PREPARATION OF REPORT
|
Professional
|
Both
|
$252.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
90000014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$252.42 |
| Rate for Payer: Aetna Commercial |
$112.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$252.42
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cigna Commercial |
$104.15
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.34
|
| Rate for Payer: Multiplan PHCS |
$151.45
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$176.69
|
| Rate for Payer: UHCCP Medicaid |
$88.35
|
|
|
PREPARATION OF REPORT
|
Facility
|
OP
|
$252.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
90000014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$242.32 |
| Rate for Payer: Aetna Commercial |
$194.36
|
| Rate for Payer: Anthem Medicaid |
$86.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.89
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cigna Commercial |
$209.51
|
| Rate for Payer: First Health Commercial |
$239.80
|
| Rate for Payer: Humana Commercial |
$214.56
|
| Rate for Payer: Humana KY Medicaid |
$86.81
|
| Rate for Payer: Kentucky WC Medicaid |
$87.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$222.13
|
| Rate for Payer: Ohio Health Group HMO |
$189.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.25
|
| Rate for Payer: PHCS Commercial |
$242.32
|
| Rate for Payer: United Healthcare All Payer |
$222.13
|
|
|
PREPARATION OF REPORT
|
Facility
|
IP
|
$252.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
90000014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$242.32 |
| Rate for Payer: Aetna Commercial |
$194.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.89
|
| Rate for Payer: Cash Price |
$126.21
|
| Rate for Payer: Cigna Commercial |
$209.51
|
| Rate for Payer: First Health Commercial |
$239.80
|
| Rate for Payer: Humana Commercial |
$214.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$222.13
|
| Rate for Payer: Ohio Health Group HMO |
$189.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$50.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.25
|
| Rate for Payer: PHCS Commercial |
$242.32
|
| Rate for Payer: United Healthcare All Payer |
$222.13
|
|
|
PREPARATION OF REPORT(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
900P0014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$112.87 |
| Rate for Payer: Aetna Commercial |
$112.87
|
| 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 |
$104.15
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.34
|
| 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
|
|
|
PREPARATION OF REPORT(T
|
Facility
|
OP
|
$152.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
900T0014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$19.81 |
| Max. Negotiated Rate |
$146.32 |
| Rate for Payer: Aetna Commercial |
$117.36
|
| Rate for Payer: Anthem Medicaid |
$52.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.89
|
| Rate for Payer: Cash Price |
$76.21
|
| Rate for Payer: Cigna Commercial |
$126.51
|
| Rate for Payer: First Health Commercial |
$144.80
|
| Rate for Payer: Humana Commercial |
$129.56
|
| Rate for Payer: Humana KY Medicaid |
$52.42
|
| Rate for Payer: Kentucky WC Medicaid |
$52.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$53.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$134.13
|
| Rate for Payer: Ohio Health Group HMO |
$114.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.25
|
| Rate for Payer: PHCS Commercial |
$146.32
|
| Rate for Payer: United Healthcare All Payer |
$134.13
|
|
|
PREPARATION OF REPORT(T
|
Facility
|
IP
|
$152.42
|
|
|
Service Code
|
HCPCS 90889
|
| Hospital Charge Code |
900T0014
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$19.81 |
| Max. Negotiated Rate |
$146.32 |
| Rate for Payer: Aetna Commercial |
$117.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.89
|
| Rate for Payer: Cash Price |
$76.21
|
| Rate for Payer: Cigna Commercial |
$126.51
|
| Rate for Payer: First Health Commercial |
$144.80
|
| Rate for Payer: Humana Commercial |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$124.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$112.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$134.13
|
| Rate for Payer: Ohio Health Group HMO |
$114.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.25
|
| Rate for Payer: PHCS Commercial |
$146.32
|
| Rate for Payer: United Healthcare All Payer |
$134.13
|
|
|
PREPARE DONOR LUNG SINGLE
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 32855
|
| Hospital Charge Code |
76101234
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
