|
REMERON (MIRTAZAPINE) 15MG TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 68084011901
|
| Hospital Charge Code |
25001300
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| 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 |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
REMERON(MIRTAZAPINE)30MG TAB
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 68084012001
|
| Hospital Charge Code |
25001303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
REMERON(MIRTAZAPINE)30MG TAB
|
Facility
|
IP
|
$4.54
|
|
|
Service Code
|
NDC 68084012001
|
| Hospital Charge Code |
25001303
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
REM INTERROG DEV EVAL ICPMS
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 93297
|
| Hospital Charge Code |
48000090
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$21.07 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Aetna Commercial |
$42.57
|
| Rate for Payer: Anthem Medicaid |
$21.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$43.00
|
| Rate for Payer: Healthspan PPO |
$40.02
|
| Rate for Payer: Humana Medicaid |
$21.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.49
|
| Rate for Payer: Molina Healthcare Passport |
$21.07
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.28
|
|
|
REM INTERROG DEV EVAL ICPMS
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 93297
|
| Hospital Charge Code |
48000090
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
REM INTERROG DEV EVAL ICPMS
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
HCPCS 93297
|
| Hospital Charge Code |
48000090
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem Medicaid |
$80.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Humana KY Medicaid |
$80.82
|
| Rate for Payer: Kentucky WC Medicaid |
$81.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
REM INTERROG DEV EVAL SCRMS
|
Professional
|
Both
|
$271.00
|
|
|
Service Code
|
HCPCS 93298
|
| Hospital Charge Code |
48000091
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$271.00 |
| Rate for Payer: Aetna Commercial |
$48.76
|
| Rate for Payer: Anthem Medicaid |
$24.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$271.00
|
| Rate for Payer: Cash Price |
$135.50
|
| Rate for Payer: Cash Price |
$135.50
|
| Rate for Payer: Cigna Commercial |
$49.33
|
| Rate for Payer: Healthspan PPO |
$45.82
|
| Rate for Payer: Humana Medicaid |
$24.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$24.82
|
| Rate for Payer: Molina Healthcare Passport |
$24.33
|
| Rate for Payer: Multiplan PHCS |
$162.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$189.70
|
| Rate for Payer: UHCCP Medicaid |
$94.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$24.57
|
|
|
REM INTERROG DEV EVAL SCRMS
|
Facility
|
IP
|
$271.00
|
|
|
Service Code
|
HCPCS 93298
|
| Hospital Charge Code |
48000091
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$35.23 |
| Max. Negotiated Rate |
$260.16 |
| Rate for Payer: Aetna Commercial |
$208.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$211.38
|
| Rate for Payer: Cash Price |
$135.50
|
| Rate for Payer: Cigna Commercial |
$224.93
|
| Rate for Payer: First Health Commercial |
$257.45
|
| Rate for Payer: Humana Commercial |
$230.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$222.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$200.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$238.48
|
| Rate for Payer: Ohio Health Group HMO |
$203.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.01
|
| Rate for Payer: PHCS Commercial |
$260.16
|
| Rate for Payer: United Healthcare All Payer |
$238.48
|
|
|
REM INTERROG DEV EVAL SCRMS
|
Facility
|
OP
|
$271.00
|
|
|
Service Code
|
HCPCS 93298
|
| Hospital Charge Code |
48000091
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$35.23 |
| Max. Negotiated Rate |
$260.16 |
| Rate for Payer: Aetna Commercial |
$208.67
|
| Rate for Payer: Anthem Medicaid |
$93.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$211.38
|
| Rate for Payer: Cash Price |
$135.50
|
| Rate for Payer: Cigna Commercial |
$224.93
|
| Rate for Payer: First Health Commercial |
$257.45
|
| Rate for Payer: Humana Commercial |
$230.35
|
| Rate for Payer: Humana KY Medicaid |
$93.20
|
| Rate for Payer: Kentucky WC Medicaid |
$94.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$222.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$200.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$95.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$238.48
|
| Rate for Payer: Ohio Health Group HMO |
$203.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.01
|
| Rate for Payer: PHCS Commercial |
$260.16
|
| Rate for Payer: United Healthcare All Payer |
$238.48
|
|
|
REM INTERROG EVL PM/IDS
|
Facility
|
OP
|
$266.00
|
|
|
Service Code
|
HCPCS 93296
|
| Hospital Charge Code |
48000089
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$255.36 |
| Rate for Payer: Aetna Commercial |
$204.82
|
| Rate for Payer: Anthem Medicaid |
$91.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$207.48
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.02
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: Cigna Commercial |
$220.78
|
| Rate for Payer: First Health Commercial |
$252.70
|
| Rate for Payer: Humana Commercial |
$226.10
|
| Rate for Payer: Humana KY Medicaid |
$91.48
|
| Rate for Payer: Humana Medicare Advantage |
$32.61
|
| Rate for Payer: Kentucky WC Medicaid |
$92.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$196.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$93.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$234.08
|
| Rate for Payer: Ohio Health Group HMO |
$199.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.46
|
| Rate for Payer: PHCS Commercial |
$255.36
|
| Rate for Payer: United Healthcare All Payer |
$234.08
|
|
|
REM INTERROG EVL PM/IDS
|
Facility
|
IP
|
$266.00
|
|
|
Service Code
|
HCPCS 93296
|
| Hospital Charge Code |
48000089
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.58 |
| Max. Negotiated Rate |
$255.36 |
| Rate for Payer: Aetna Commercial |
$204.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$207.48
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: Cigna Commercial |
$220.78
|
| Rate for Payer: First Health Commercial |
$252.70
|
| Rate for Payer: Humana Commercial |
$226.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$218.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$196.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$234.08
|
| Rate for Payer: Ohio Health Group HMO |
$199.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$34.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.46
|
| Rate for Payer: PHCS Commercial |
$255.36
|
| Rate for Payer: United Healthcare All Payer |
$234.08
|
|
|
REM INTERROG EVL PM/LDLS PM
|
Professional
|
Both
|
$287.00
|
|
|
Service Code
|
HCPCS 93294
|
| Hospital Charge Code |
48000087
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$30.26 |
| Max. Negotiated Rate |
$287.00 |
| Rate for Payer: Aetna Commercial |
$60.75
|
| Rate for Payer: Anthem Medicaid |
$30.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$287.00
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$61.38
|
| Rate for Payer: Healthspan PPO |
$57.10
|
| Rate for Payer: Humana Medicaid |
$30.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$30.87
|
| Rate for Payer: Molina Healthcare Passport |
$30.26
|
| Rate for Payer: Multiplan PHCS |
$172.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$200.90
|
| Rate for Payer: UHCCP Medicaid |
$100.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$30.56
|
|
|
REM INTERROG EVL PM/LDLS PM
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
HCPCS 93294
|
| Hospital Charge Code |
48000087
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem Medicaid |
$98.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Humana KY Medicaid |
$98.70
|
| Rate for Payer: Kentucky WC Medicaid |
$99.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.97
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
REM INTERROG EVL PM/LDLS PM
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
HCPCS 93294
|
| Hospital Charge Code |
48000087
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.97
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
REMINYL (GALANIT HYDRO)4MG TAB
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 65862045860
|
| Hospital Charge Code |
25001304
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
REMINYL (GALANIT HYDRO)4MG TAB
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 65862045860
|
| Hospital Charge Code |
25001304
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
REM MNTR WIRLSS PLMRT PRSRSNSR
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 93264
|
| Hospital Charge Code |
76102473
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.77 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.77
|
| Rate for Payer: Anthem Medicaid |
$29.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Humana Medicaid |
$29.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$50.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.61
|
| Rate for Payer: Molina Healthcare Passport |
$29.03
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$30.21
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.32
|
|
|
REM MNTR WIRLSS PLMRT PRSRSNSR
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
HCPCS 93264
|
| Hospital Charge Code |
76102473
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem Medicaid |
$80.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Humana KY Medicaid |
$80.82
|
| Rate for Payer: Kentucky WC Medicaid |
$81.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
REM MNTR WIRLSS PLMRT PRSRSNSR
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 93264
|
| Hospital Charge Code |
76102473
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$47.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$72.85
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
REM MNTR WIRLSS PLMRT PRSRSNSR
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 93264
|
| Hospital Charge Code |
761P2473
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$28.77 |
| Max. Negotiated Rate |
$235.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$28.77
|
| Rate for Payer: Anthem Medicaid |
$29.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.00
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$85.96
|
| Rate for Payer: Humana Medicaid |
$29.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$50.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.61
|
| Rate for Payer: Molina Healthcare Passport |
$29.03
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$164.50
|
| Rate for Payer: UHCCP Medicaid |
$30.21
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$29.32
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
761P0309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$274.70 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$702.17
|
| Rate for Payer: Anthem Medicaid |
$274.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$667.17
|
| Rate for Payer: Healthspan PPO |
$561.45
|
| Rate for Payer: Humana Medicaid |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$630.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$280.19
|
| Rate for Payer: Molina Healthcare Passport |
$274.70
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$315.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$277.45
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
76100309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$274.70 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$702.17
|
| Rate for Payer: Anthem Medicaid |
$274.70
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$667.17
|
| Rate for Payer: Healthspan PPO |
$561.45
|
| Rate for Payer: Humana Medicaid |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$630.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$280.19
|
| Rate for Payer: Molina Healthcare Passport |
$274.70
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$315.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$277.45
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
76100309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem Medicaid |
$309.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Humana KY Medicaid |
$309.51
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$312.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
REM. OF INTACT MAMMARY IMPLANT
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 19328
|
| Hospital Charge Code |
76100309
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
REMOT AFTLOAD HDR 2-12 CHANEL
|
Professional
|
Both
|
$6,377.00
|
|
|
Service Code
|
HCPCS 77771
|
| Hospital Charge Code |
33300033
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$247.61 |
| Max. Negotiated Rate |
$6,377.00 |
| Rate for Payer: Anthem Medicaid |
$450.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,377.00
|
| Rate for Payer: Cash Price |
$3,188.50
|
| Rate for Payer: Cash Price |
$3,188.50
|
| Rate for Payer: Cigna Commercial |
$942.31
|
| Rate for Payer: Humana Medicaid |
$450.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$247.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$459.11
|
| Rate for Payer: Molina Healthcare Passport |
$450.11
|
| Rate for Payer: Multiplan PHCS |
$3,826.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,463.90
|
| Rate for Payer: UHCCP Medicaid |
$2,231.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$454.61
|
|
