|
PREG TEST BLOOD QUANTITATIVE
|
Facility
|
OP
|
$134.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
30000560
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem Medicaid |
$15.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$107.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.05
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Humana KY Medicaid |
$15.05
|
| Rate for Payer: Humana Medicare Advantage |
$15.05
|
| Rate for Payer: Kentucky WC Medicaid |
$15.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.46
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
PREG TEST BLOOD QUANTITATIVE
|
Facility
|
IP
|
$134.00
|
|
|
Service Code
|
HCPCS 84702
|
| Hospital Charge Code |
30000560
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$40.20 |
| Max. Negotiated Rate |
$128.64 |
| Rate for Payer: Aetna Commercial |
$103.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$107.60
|
| Rate for Payer: Cash Price |
$67.00
|
| Rate for Payer: Cigna Commercial |
$111.22
|
| Rate for Payer: First Health Commercial |
$127.30
|
| Rate for Payer: Humana Commercial |
$113.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.92
|
| Rate for Payer: Ohio Health Group HMO |
$100.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$107.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.46
|
| Rate for Payer: PHCS Commercial |
$128.64
|
| Rate for Payer: United Healthcare All Payer |
$117.92
|
|
|
PRE HYDR EVANS WEDGE 12MM
|
Facility
|
IP
|
$9,935.00
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PRE HYDR EVANS WEDGE 12MM
|
Facility
|
OP
|
$9,935.00
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,980.50 |
| Max. Negotiated Rate |
$9,537.60 |
| Rate for Payer: Aetna Commercial |
$7,649.95
|
| Rate for Payer: Anthem Medicaid |
$3,416.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,749.30
|
| Rate for Payer: Cash Price |
$4,967.50
|
| Rate for Payer: Cigna Commercial |
$8,246.05
|
| Rate for Payer: First Health Commercial |
$9,438.25
|
| Rate for Payer: Humana Commercial |
$8,444.75
|
| Rate for Payer: Humana KY Medicaid |
$3,416.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,451.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,146.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,332.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,980.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,485.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,742.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,451.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,948.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,643.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,855.15
|
| Rate for Payer: PHCS Commercial |
$9,537.60
|
| Rate for Payer: United Healthcare All Payer |
$8,742.80
|
|
|
PREMARIN(CONJ ESTR 1.25MG/1TAB
|
Facility
|
OP
|
$24.07
|
|
|
Service Code
|
NDC 46110481
|
| Hospital Charge Code |
25003817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem Medicaid |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Humana KY Medicaid |
$8.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(CONJ ESTR 1.25MG/1TAB
|
Facility
|
IP
|
$24.07
|
|
|
Service Code
|
NDC 46110481
|
| Hospital Charge Code |
25003817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(CONJ ESTR .625MG/1TAB
|
Facility
|
OP
|
$9.11
|
|
|
Service Code
|
NDC 66267017430
|
| Hospital Charge Code |
25003815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.73 |
| 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 |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| 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 |
$2.73 |
| 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 |
$7.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.29
|
| Rate for Payer: PHCS Commercial |
$8.75
|
| Rate for Payer: United Healthcare All Payer |
$8.02
|
|
|
PREMARIN(CONJ ESTRO .9MG/1TAB
|
Facility
|
IP
|
$24.07
|
|
|
Service Code
|
NDC 46110381
|
| Hospital Charge Code |
25003816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(CONJ ESTRO .9MG/1TAB
|
Facility
|
OP
|
$24.07
|
|
|
Service Code
|
NDC 46110381
|
| Hospital Charge Code |
25003816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem Medicaid |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Humana KY Medicaid |
$8.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(CONJ ESTROG .3MG/1TAB
|
Facility
|
OP
|
$24.07
|
|
|
Service Code
|
NDC 46110081
|
| Hospital Charge Code |
25001216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem Medicaid |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Humana KY Medicaid |
$8.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(CONJ ESTROG .3MG/1TAB
|
Facility
|
IP
|
$24.07
|
|
|
Service Code
|
NDC 46110081
|
| Hospital Charge Code |
25001216
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(CONJ ESTROGE 25MG/5ML
|
Facility
|
OP
|
$956.88
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
25002055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$329.07 |
| Max. Negotiated Rate |
$918.60 |
| Rate for Payer: Aetna Commercial |
$736.80
|
| Rate for Payer: Anthem Medicaid |
$329.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$390.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$746.37
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$547.04
|
| Rate for Payer: CareSource Just4Me Medicare |
$527.50
|
| Rate for Payer: Cash Price |
$478.44
|
| Rate for Payer: Cash Price |
$478.44
|
| Rate for Payer: Cigna Commercial |
$794.21
|
| Rate for Payer: First Health Commercial |
$909.04
|
| Rate for Payer: Humana Commercial |
$813.35
|
| Rate for Payer: Humana KY Medicaid |
$329.07
|
| Rate for Payer: Humana Medicare Advantage |
$390.74
|
| Rate for Payer: Kentucky WC Medicaid |
$332.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$784.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$706.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$335.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$842.05
|
| Rate for Payer: Ohio Health Group HMO |
$717.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$765.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$832.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$660.25
|
| Rate for Payer: PHCS Commercial |
$918.60
|
| Rate for Payer: United Healthcare All Payer |
$842.05
|
|
|
PREMARIN(CONJ ESTROGE 25MG/5ML
|
Facility
|
IP
|
$956.88
|
|
|
Service Code
|
HCPCS J1410
|
| Hospital Charge Code |
25002055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$287.06 |
| Max. Negotiated Rate |
$918.60 |
| Rate for Payer: Aetna Commercial |
$736.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$746.37
|
| Rate for Payer: Cash Price |
$478.44
|
| Rate for Payer: Cigna Commercial |
$794.21
|
| Rate for Payer: First Health Commercial |
$909.04
|
| Rate for Payer: Humana Commercial |
$813.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$784.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$706.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$287.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$842.05
|
| Rate for Payer: Ohio Health Group HMO |
$717.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$765.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$832.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$660.25
|
| Rate for Payer: PHCS Commercial |
$918.60
|
| Rate for Payer: United Healthcare All Payer |
$842.05
|
|
|
PREMARIN (CONJ ESTROGEN 42.5GM
|
Facility
|
OP
|
$35.53
|
|
|
Service Code
|
NDC 46087221
|
| Hospital Charge Code |
25001214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$34.11 |
| Rate for Payer: Aetna Commercial |
$27.36
|
| Rate for Payer: Anthem Medicaid |
$12.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.71
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cigna Commercial |
$29.49
|
| Rate for Payer: First Health Commercial |
$33.75
|
| Rate for Payer: Humana Commercial |
$30.20
|
| Rate for Payer: Humana KY Medicaid |
$12.22
|
| Rate for Payer: Kentucky WC Medicaid |
$12.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.27
|
| Rate for Payer: Ohio Health Group HMO |
$26.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.52
|
| Rate for Payer: PHCS Commercial |
$34.11
|
| Rate for Payer: United Healthcare All Payer |
$31.27
|
|
|
PREMARIN (CONJ ESTROGEN 42.5GM
|
Facility
|
IP
|
$35.53
|
|
|
Service Code
|
NDC 46087221
|
| Hospital Charge Code |
25001214
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$34.11 |
| Rate for Payer: Aetna Commercial |
$27.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.71
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cigna Commercial |
$29.49
|
| Rate for Payer: First Health Commercial |
$33.75
|
| Rate for Payer: Humana Commercial |
$30.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$29.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$26.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$31.27
|
| Rate for Payer: Ohio Health Group HMO |
$26.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.52
|
| Rate for Payer: PHCS Commercial |
$34.11
|
| Rate for Payer: United Healthcare All Payer |
$31.27
|
|
|
PREMARIN(ESTROGENS) 0.45MG TAB
|
Facility
|
OP
|
$24.07
|
|
|
Service Code
|
NDC 46110181
|
| Hospital Charge Code |
25001217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem Medicaid |
$8.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Humana KY Medicaid |
$8.28
|
| Rate for Payer: Kentucky WC Medicaid |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PREMARIN(ESTROGENS) 0.45MG TAB
|
Facility
|
IP
|
$24.07
|
|
|
Service Code
|
NDC 46110181
|
| Hospital Charge Code |
25001217
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.22 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$18.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.77
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cigna Commercial |
$19.98
|
| Rate for Payer: First Health Commercial |
$22.87
|
| Rate for Payer: Humana Commercial |
$20.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.18
|
| Rate for Payer: Ohio Health Group HMO |
$18.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.61
|
| Rate for Payer: PHCS Commercial |
$23.11
|
| Rate for Payer: United Healthcare All Payer |
$21.18
|
|
|
PRE-OP SERVICE LVRS 10-15 DOS
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
HCPCS G0303
|
| Hospital Charge Code |
94000014
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PRE-OP SERVICE LVRS 10-15 DOS
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
HCPCS G0303
|
| Hospital Charge Code |
94000014
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$402.82 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem Medicaid |
$19.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Humana KY Medicaid |
$19.09
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$19.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PRE-OP SERVICE LVRS 1-9 DOS
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
HCPCS G0304
|
| Hospital Charge Code |
94000015
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$686.36 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem Medicaid |
$19.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Humana KY Medicaid |
$19.09
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$19.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PRE-OP SERVICE LVRS 1-9 DOS
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
HCPCS G0304
|
| Hospital Charge Code |
94000015
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PRE-OP SERVICE LVRS COMPLETE
|
Facility
|
OP
|
$55.50
|
|
|
Service Code
|
HCPCS G0302
|
| Hospital Charge Code |
94000013
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$19.09 |
| Max. Negotiated Rate |
$686.36 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem Medicaid |
$19.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Humana KY Medicaid |
$19.09
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$19.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PRE-OP SERVICE LVRS COMPLETE
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
HCPCS G0302
|
| Hospital Charge Code |
94000013
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
|
PRE-OP SERVICE LVRS MIN 6
|
Facility
|
IP
|
$55.50
|
|
|
Service Code
|
HCPCS G0305
|
| Hospital Charge Code |
94000016
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$53.28 |
| Rate for Payer: Aetna Commercial |
$42.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43.29
|
| Rate for Payer: Cash Price |
$27.75
|
| Rate for Payer: Cigna Commercial |
$46.06
|
| Rate for Payer: First Health Commercial |
$52.73
|
| Rate for Payer: Humana Commercial |
$47.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.84
|
| Rate for Payer: Ohio Health Group HMO |
$41.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$44.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.30
|
| Rate for Payer: PHCS Commercial |
$53.28
|
| Rate for Payer: United Healthcare All Payer |
$48.84
|
|
