|
REGLAN (METOCLOPRAMID 5MG/1TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 60687062001
|
| Hospital Charge Code |
25001296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
REGLAN (METOCLOPRAMID 5MG/1TAB
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 60687062001
|
| Hospital Charge Code |
25001296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
OP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
25002335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem Medicaid |
$26.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Humana KY Medicaid |
$26.54
|
| Rate for Payer: Kentucky WC Medicaid |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
OP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
63600056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem Medicaid |
$26.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Humana KY Medicaid |
$26.54
|
| Rate for Payer: Kentucky WC Medicaid |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
IP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
25002335
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
IP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
636T0056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
OP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
636T0056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem Medicaid |
$26.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Humana KY Medicaid |
$26.54
|
| Rate for Payer: Kentucky WC Medicaid |
$26.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
IP
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
63600056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.15 |
| Max. Negotiated Rate |
$74.09 |
| Rate for Payer: Aetna Commercial |
$59.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cigna Commercial |
$64.06
|
| Rate for Payer: First Health Commercial |
$73.32
|
| Rate for Payer: Humana Commercial |
$65.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.92
|
| Rate for Payer: Ohio Health Group HMO |
$57.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.25
|
| Rate for Payer: PHCS Commercial |
$74.09
|
| Rate for Payer: United Healthcare All Payer |
$67.92
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Professional
|
Both
|
$77.18
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
63600056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$46.31 |
| Rate for Payer: Aetna Commercial |
$1.55
|
| Rate for Payer: Ambetter Exchange |
$1.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.20
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Cash Price |
$38.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.00
|
| Rate for Payer: Multiplan PHCS |
$46.31
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1.30
|
| Rate for Payer: UHCCP Medicaid |
$27.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$1.00
|
|
|
REGONOL PYRIDOSTIGMINE 10MG2ML
|
Facility
|
IP
|
$122.36
|
|
|
Service Code
|
NDC 781304072
|
| Hospital Charge Code |
25003401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.71 |
| Max. Negotiated Rate |
$117.47 |
| Rate for Payer: Aetna Commercial |
$94.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.44
|
| Rate for Payer: Cash Price |
$61.18
|
| Rate for Payer: Cigna Commercial |
$101.56
|
| Rate for Payer: First Health Commercial |
$116.24
|
| Rate for Payer: Humana Commercial |
$104.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.68
|
| Rate for Payer: Ohio Health Group HMO |
$91.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.43
|
| Rate for Payer: PHCS Commercial |
$117.47
|
| Rate for Payer: United Healthcare All Payer |
$107.68
|
|
|
REGONOL PYRIDOSTIGMINE 10MG2ML
|
Facility
|
OP
|
$122.36
|
|
|
Service Code
|
NDC 781304072
|
| Hospital Charge Code |
25003401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.71 |
| Max. Negotiated Rate |
$117.47 |
| Rate for Payer: Aetna Commercial |
$94.22
|
| Rate for Payer: Anthem Medicaid |
$42.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.44
|
| Rate for Payer: Cash Price |
$61.18
|
| Rate for Payer: Cigna Commercial |
$101.56
|
| Rate for Payer: First Health Commercial |
$116.24
|
| Rate for Payer: Humana Commercial |
$104.01
|
| Rate for Payer: Humana KY Medicaid |
$42.08
|
| Rate for Payer: Kentucky WC Medicaid |
$42.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.68
|
| Rate for Payer: Ohio Health Group HMO |
$91.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$97.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.43
|
| Rate for Payer: PHCS Commercial |
$117.47
|
| Rate for Payer: United Healthcare All Payer |
$107.68
|
|
|
REGRANEX (BECAPLERMIN) 15 GRAM
|
Facility
|
IP
|
$140.98
|
|
|
Service Code
|
NDC 50484081015
|
| Hospital Charge Code |
25001297
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.29 |
| Max. Negotiated Rate |
$135.34 |
| Rate for Payer: Aetna Commercial |
$108.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Cash Price |
$70.49
|
| Rate for Payer: Cigna Commercial |
$117.01
|
| Rate for Payer: First Health Commercial |
$133.93
|
| Rate for Payer: Humana Commercial |
$119.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.06
|
| Rate for Payer: Ohio Health Group HMO |
$105.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.28
|
| Rate for Payer: PHCS Commercial |
$135.34
|
| Rate for Payer: United Healthcare All Payer |
$124.06
|
|
|
REGRANEX (BECAPLERMIN) 15 GRAM
|
Facility
|
OP
|
$140.98
|
|
|
Service Code
|
NDC 50484081015
|
| Hospital Charge Code |
25001297
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.29 |
| Max. Negotiated Rate |
$135.34 |
| Rate for Payer: Aetna Commercial |
$108.55
|
| Rate for Payer: Anthem Medicaid |
$48.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Cash Price |
$70.49
|
| Rate for Payer: Cigna Commercial |
$117.01
|
| Rate for Payer: First Health Commercial |
$133.93
|
| Rate for Payer: Humana Commercial |
$119.83
|
| Rate for Payer: Humana KY Medicaid |
$48.48
|
| Rate for Payer: Kentucky WC Medicaid |
$48.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$115.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$104.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$49.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$124.06
|
| Rate for Payer: Ohio Health Group HMO |
$105.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$112.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$97.28
|
| Rate for Payer: PHCS Commercial |
$135.34
|
| Rate for Payer: United Healthcare All Payer |
$124.06
|
|
|
REG THICK-SEVERE WRINKLE
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200671
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
REHAB ROOM RATE
|
Facility
|
IP
|
$2,439.00
|
|
| Hospital Charge Code |
11800001
|
|
Hospital Revenue Code
|
118
|
| Min. Negotiated Rate |
$731.70 |
| Max. Negotiated Rate |
$2,341.44 |
| Rate for Payer: Aetna Commercial |
$1,878.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,902.42
|
| Rate for Payer: Cash Price |
$1,219.50
|
| Rate for Payer: Cigna Commercial |
$2,024.37
|
| Rate for Payer: First Health Commercial |
$2,317.05
|
| Rate for Payer: Humana Commercial |
$2,073.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,999.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,799.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$731.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,146.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,829.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,951.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,121.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,682.91
|
| Rate for Payer: PHCS Commercial |
$2,341.44
|
| Rate for Payer: United Healthcare All Payer |
$2,146.32
|
|
|
REIMPLANT ARTERY EACH
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
76101418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.87 |
| Max. Negotiated Rate |
$268.30 |
| Rate for Payer: Aetna Commercial |
$268.30
|
| Rate for Payer: Ambetter Exchange |
$137.64
|
| Rate for Payer: Anthem Medicaid |
$122.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.17
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$256.07
|
| Rate for Payer: Healthspan PPO |
$263.79
|
| Rate for Payer: Humana Medicaid |
$122.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$205.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.33
|
| Rate for Payer: Molina Healthcare Passport |
$122.87
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.93
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.64
|
|
|
REIMPLANT ARTERY EACH
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
76101418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT ARTERY EACH
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
76101418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT ARTERY EACH(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 35697
|
| Hospital Charge Code |
761P1418
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.87 |
| Max. Negotiated Rate |
$268.30 |
| Rate for Payer: Aetna Commercial |
$268.30
|
| Rate for Payer: Ambetter Exchange |
$137.64
|
| Rate for Payer: Anthem Medicaid |
$122.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$137.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$137.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$165.17
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$256.07
|
| Rate for Payer: Healthspan PPO |
$263.79
|
| Rate for Payer: Humana Medicaid |
$122.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$205.15
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$137.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.33
|
| Rate for Payer: Molina Healthcare Passport |
$122.87
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.93
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$137.64
|
|
|
REIMPLANT RENAL ART W/SAPH VEI
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 37799
|
| Hospital Charge Code |
76102890
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.00 |
| Max. Negotiated Rate |
$384.00 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT RENAL ART W/SAPH VEI
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 37799
|
| Hospital Charge Code |
76102890
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.56 |
| Max. Negotiated Rate |
$799.76 |
| Rate for Payer: Aetna Commercial |
$308.00
|
| Rate for Payer: Anthem Medicaid |
$137.56
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$571.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$312.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$799.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$771.20
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$332.00
|
| Rate for Payer: First Health Commercial |
$380.00
|
| Rate for Payer: Humana Commercial |
$340.00
|
| Rate for Payer: Humana KY Medicaid |
$137.56
|
| Rate for Payer: Humana Medicare Advantage |
$571.26
|
| Rate for Payer: Kentucky WC Medicaid |
$138.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$328.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$295.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$685.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$140.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$352.00
|
| Rate for Payer: Ohio Health Group HMO |
$300.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$348.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$276.00
|
| Rate for Payer: PHCS Commercial |
$384.00
|
| Rate for Payer: United Healthcare All Payer |
$352.00
|
|
|
REIMPLANT RENAL ART W/SAPH VEI
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 37799
|
| Hospital Charge Code |
76102890
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$280.00 |
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
|
|
REIMPLANT URETER IN BLADDER
|
Facility
|
OP
|
$1,230.00
|
|
|
Service Code
|
HCPCS 50785
|
| Hospital Charge Code |
76102812
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.00 |
| Max. Negotiated Rate |
$1,180.80 |
| Rate for Payer: Aetna Commercial |
$947.10
|
| Rate for Payer: Anthem Medicaid |
$423.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,020.90
|
| Rate for Payer: First Health Commercial |
$1,168.50
|
| Rate for Payer: Humana Commercial |
$1,045.50
|
| Rate for Payer: Humana KY Medicaid |
$423.00
|
| Rate for Payer: Kentucky WC Medicaid |
$427.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,008.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$907.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$369.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$431.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,082.40
|
| Rate for Payer: Ohio Health Group HMO |
$922.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$984.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$848.70
|
| Rate for Payer: PHCS Commercial |
$1,180.80
|
| Rate for Payer: United Healthcare All Payer |
$1,082.40
|
|
|
REIMPLANT URETER IN BLADDER
|
Professional
|
Both
|
$2,750.00
|
|
|
Service Code
|
HCPCS 50780
|
| Hospital Charge Code |
76102057
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$907.44 |
| Max. Negotiated Rate |
$1,780.98 |
| Rate for Payer: Aetna Commercial |
$1,780.98
|
| Rate for Payer: Ambetter Exchange |
$1,052.92
|
| Rate for Payer: Anthem Medicaid |
$907.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,052.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,052.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,263.50
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cash Price |
$1,375.00
|
| Rate for Payer: Cigna Commercial |
$1,592.01
|
| Rate for Payer: Healthspan PPO |
$1,424.05
|
| Rate for Payer: Humana Medicaid |
$907.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,503.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,052.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,052.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$925.59
|
| Rate for Payer: Molina Healthcare Passport |
$907.44
|
| Rate for Payer: Multiplan PHCS |
$1,650.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,368.80
|
| Rate for Payer: UHCCP Medicaid |
$962.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$916.51
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,052.92
|
|
|
REIMPLANT URETER IN BLADDER
|
Professional
|
Both
|
$1,230.00
|
|
|
Service Code
|
HCPCS 50785
|
| Hospital Charge Code |
76102812
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$430.50 |
| Max. Negotiated Rate |
$1,968.83 |
| Rate for Payer: Aetna Commercial |
$1,968.83
|
| Rate for Payer: Ambetter Exchange |
$1,148.08
|
| Rate for Payer: Anthem Medicaid |
$1,019.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,148.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,148.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,377.70
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cash Price |
$615.00
|
| Rate for Payer: Cigna Commercial |
$1,753.74
|
| Rate for Payer: Healthspan PPO |
$1,574.26
|
| Rate for Payer: Humana Medicaid |
$1,019.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,650.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,148.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,148.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,039.65
|
| Rate for Payer: Molina Healthcare Passport |
$1,019.26
|
| Rate for Payer: Multiplan PHCS |
$738.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,492.50
|
| Rate for Payer: UHCCP Medicaid |
$430.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,029.45
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,148.08
|
|
