|
SALIVARY GLAND PROCEDURES
|
Facility
|
IP
|
$13,893.95
|
|
|
Service Code
|
MSDRG 139
|
| Min. Negotiated Rate |
$9,428.04 |
| Max. Negotiated Rate |
$13,893.95 |
| Rate for Payer: Anthem Medicaid |
$9,428.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,924.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,893.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$13,397.74
|
| Rate for Payer: Humana KY Medicaid |
$9,428.04
|
| Rate for Payer: Humana Medicare Advantage |
$9,924.25
|
| Rate for Payer: Kentucky WC Medicaid |
$9,522.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,909.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,616.60
|
|
|
SALIVA SUBSTITUTE LIQ 12 120ML
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
25001359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| 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 |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| 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 |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
SALIVA SUBSTITUTE LIQ 12 120ML
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 48582000155
|
| Hospital Charge Code |
25001359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna Commercial |
$0.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.05
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.05
|
| Rate for Payer: First Health Commercial |
$0.06
|
| Rate for Payer: Humana Commercial |
$0.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.05
|
| 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 |
$0.05
|
| Rate for Payer: Ohio Health Group HMO |
$0.05
|
| 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 |
$0.06
|
| Rate for Payer: United Healthcare All Payer |
$0.05
|
|
|
SALONPAS HOT 0.025% ADH PATCH
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 46581070003
|
| Hospital Charge Code |
25001361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
SALONPAS HOT 0.025% ADH PATCH
|
Facility
|
OP
|
$9.05
|
|
|
Service Code
|
NDC 46581070003
|
| Hospital Charge Code |
25001361
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.81
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
SALPINGECTOMY
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 58700
|
| Hospital Charge Code |
76102255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$375.33 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,157.02
|
| Rate for Payer: Anthem Medicaid |
$375.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,119.63
|
| Rate for Payer: Healthspan PPO |
$1,120.29
|
| Rate for Payer: Humana Medicaid |
$375.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,005.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$382.84
|
| Rate for Payer: Molina Healthcare Passport |
$375.33
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.08
|
|
|
SALPINGECTOMY
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 58700
|
| Hospital Charge Code |
76102255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
SALPINGECTOMY
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 58700
|
| Hospital Charge Code |
76102255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
SALPINGECTOMY(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 58700
|
| Hospital Charge Code |
761P2255
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$375.33 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,157.02
|
| Rate for Payer: Anthem Medicaid |
$375.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,119.63
|
| Rate for Payer: Healthspan PPO |
$1,120.29
|
| Rate for Payer: Humana Medicaid |
$375.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,005.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$382.84
|
| Rate for Payer: Molina Healthcare Passport |
$375.33
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.08
|
|
|
SALSALATE 500MG TAB
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 51293080301
|
| Hospital Charge Code |
25001362
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
SALSALATE 500MG TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 51293080301
|
| Hospital Charge Code |
25001362
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
SAME DAY NB DISCHARGE
|
Professional
|
Both
|
$373.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
51000119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.12 |
| Max. Negotiated Rate |
$373.00 |
| Rate for Payer: Aetna Commercial |
$119.25
|
| Rate for Payer: Anthem Medicaid |
$61.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$373.00
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: Healthspan PPO |
$88.64
|
| Rate for Payer: Humana Medicaid |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.34
|
| Rate for Payer: Molina Healthcare Passport |
$61.12
|
| Rate for Payer: Multiplan PHCS |
$223.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$261.10
|
| Rate for Payer: UHCCP Medicaid |
$130.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.73
|
|
|
SAME DAY NB DISCHARGE
|
Facility
|
OP
|
$373.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
51000119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.49 |
| Max. Negotiated Rate |
$358.08 |
| Rate for Payer: Aetna Commercial |
$287.21
|
| Rate for Payer: Anthem Medicaid |
$128.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$309.59
|
| Rate for Payer: First Health Commercial |
$354.35
|
| Rate for Payer: Humana Commercial |
$317.05
|
| Rate for Payer: Humana KY Medicaid |
$128.27
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$129.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$275.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$130.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$328.24
|
| Rate for Payer: Ohio Health Group HMO |
$279.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.63
|
| Rate for Payer: PHCS Commercial |
$358.08
|
| Rate for Payer: United Healthcare All Payer |
$328.24
|
|
|
SAME DAY NB DISCHARGE
|
Facility
|
IP
|
$373.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
51000119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.49 |
| Max. Negotiated Rate |
$358.08 |
| Rate for Payer: Aetna Commercial |
$287.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$290.94
|
| Rate for Payer: Cash Price |
$186.50
|
| Rate for Payer: Cigna Commercial |
$309.59
|
| Rate for Payer: First Health Commercial |
$354.35
|
| Rate for Payer: Humana Commercial |
$317.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$305.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$275.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$111.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$328.24
|
| Rate for Payer: Ohio Health Group HMO |
$279.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$48.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$115.63
|
| Rate for Payer: PHCS Commercial |
$358.08
|
| Rate for Payer: United Healthcare All Payer |
$328.24
|
|
|
SAME DAY NB DISCHARGE(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
510P0119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$61.12 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$119.25
|
| Rate for Payer: Anthem Medicaid |
$61.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$121.18
|
| Rate for Payer: Healthspan PPO |
$88.64
|
| Rate for Payer: Humana Medicaid |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.34
|
| Rate for Payer: Molina Healthcare Passport |
$61.12
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.73
|
|
|
SAME DAY NB DISCHARGE(T
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
510T0119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem Medicaid |
$59.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Humana KY Medicaid |
$59.49
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$60.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$60.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
SAME DAY NB DISCHARGE(T
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
HCPCS 99463
|
| Hospital Charge Code |
510T0119
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.49 |
| Max. Negotiated Rate |
$166.08 |
| Rate for Payer: Aetna Commercial |
$133.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$134.94
|
| Rate for Payer: Cash Price |
$86.50
|
| Rate for Payer: Cigna Commercial |
$143.59
|
| Rate for Payer: First Health Commercial |
$164.35
|
| Rate for Payer: Humana Commercial |
$147.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$141.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$127.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$152.24
|
| Rate for Payer: Ohio Health Group HMO |
$129.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$34.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.63
|
| Rate for Payer: PHCS Commercial |
$166.08
|
| Rate for Payer: United Healthcare All Payer |
$152.24
|
|
|
SAMSCA 15MG TABLET
|
Facility
|
IP
|
$690.20
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
25001363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.73 |
| Max. Negotiated Rate |
$662.59 |
| Rate for Payer: Aetna Commercial |
$531.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.36
|
| Rate for Payer: Cash Price |
$345.10
|
| Rate for Payer: Cigna Commercial |
$572.87
|
| Rate for Payer: First Health Commercial |
$655.69
|
| Rate for Payer: Humana Commercial |
$586.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.38
|
| Rate for Payer: Ohio Health Group HMO |
$517.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.96
|
| Rate for Payer: PHCS Commercial |
$662.59
|
| Rate for Payer: United Healthcare All Payer |
$607.38
|
|
|
SAMSCA 15MG TABLET
|
Facility
|
OP
|
$690.20
|
|
|
Service Code
|
NDC 59148002050
|
| Hospital Charge Code |
25001363
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.73 |
| Max. Negotiated Rate |
$662.59 |
| Rate for Payer: Aetna Commercial |
$531.45
|
| Rate for Payer: Anthem Medicaid |
$237.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$538.36
|
| Rate for Payer: Cash Price |
$345.10
|
| Rate for Payer: Cigna Commercial |
$572.87
|
| Rate for Payer: First Health Commercial |
$655.69
|
| Rate for Payer: Humana Commercial |
$586.67
|
| Rate for Payer: Humana KY Medicaid |
$237.36
|
| Rate for Payer: Kentucky WC Medicaid |
$239.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$565.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$509.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$242.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$607.38
|
| Rate for Payer: Ohio Health Group HMO |
$517.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$138.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$89.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$213.96
|
| Rate for Payer: PHCS Commercial |
$662.59
|
| Rate for Payer: United Healthcare All Payer |
$607.38
|
|
|
SAMSCA 30 MG TABLET
|
Facility
|
OP
|
$709.64
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
25001364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$681.25 |
| Rate for Payer: Aetna Commercial |
$546.42
|
| Rate for Payer: Anthem Medicaid |
$244.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$553.52
|
| Rate for Payer: Cash Price |
$354.82
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: First Health Commercial |
$674.16
|
| Rate for Payer: Humana Commercial |
$603.19
|
| Rate for Payer: Humana KY Medicaid |
$244.05
|
| Rate for Payer: Kentucky WC Medicaid |
$246.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$581.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$523.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$212.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$248.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$624.48
|
| Rate for Payer: Ohio Health Group HMO |
$532.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$219.99
|
| Rate for Payer: PHCS Commercial |
$681.25
|
| Rate for Payer: United Healthcare All Payer |
$624.48
|
|
|
SAMSCA 30 MG TABLET
|
Facility
|
IP
|
$709.64
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
25001364
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.25 |
| Max. Negotiated Rate |
$681.25 |
| Rate for Payer: Aetna Commercial |
$546.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$553.52
|
| Rate for Payer: Cash Price |
$354.82
|
| Rate for Payer: Cigna Commercial |
$589.00
|
| Rate for Payer: First Health Commercial |
$674.16
|
| Rate for Payer: Humana Commercial |
$603.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$581.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$523.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$212.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$624.48
|
| Rate for Payer: Ohio Health Group HMO |
$532.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$141.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$92.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$219.99
|
| Rate for Payer: PHCS Commercial |
$681.25
|
| Rate for Payer: United Healthcare All Payer |
$624.48
|
|
|
SANDOSTATIN 25MCG 100MCG/1ML V
|
Facility
|
OP
|
$54.17
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial |
$41.71
|
| Rate for Payer: Anthem Medicaid |
$18.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.25
|
| Rate for Payer: Cash Price |
$27.09
|
| Rate for Payer: Cigna Commercial |
$44.96
|
| Rate for Payer: First Health Commercial |
$51.46
|
| Rate for Payer: Humana Commercial |
$46.04
|
| Rate for Payer: Humana KY Medicaid |
$18.63
|
| Rate for Payer: Kentucky WC Medicaid |
$18.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.67
|
| Rate for Payer: Ohio Health Group HMO |
$40.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.79
|
| Rate for Payer: PHCS Commercial |
$52.00
|
| Rate for Payer: United Healthcare All Payer |
$47.67
|
|
|
SANDOSTATIN 25MCG 100MCG/1ML V
|
Facility
|
IP
|
$54.17
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002265
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna Commercial |
$41.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.25
|
| Rate for Payer: Cash Price |
$27.09
|
| Rate for Payer: Cigna Commercial |
$44.96
|
| Rate for Payer: First Health Commercial |
$51.46
|
| Rate for Payer: Humana Commercial |
$46.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.67
|
| Rate for Payer: Ohio Health Group HMO |
$40.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.79
|
| Rate for Payer: PHCS Commercial |
$52.00
|
| Rate for Payer: United Healthcare All Payer |
$47.67
|
|
|
SANDOSTATIN25MCG 500MCG 1MLAMP
|
Facility
|
OP
|
$205.69
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.74 |
| Max. Negotiated Rate |
$197.46 |
| Rate for Payer: Aetna Commercial |
$158.38
|
| Rate for Payer: Anthem Medicaid |
$70.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.44
|
| Rate for Payer: Cash Price |
$102.84
|
| Rate for Payer: Cigna Commercial |
$170.72
|
| Rate for Payer: First Health Commercial |
$195.41
|
| Rate for Payer: Humana Commercial |
$174.84
|
| Rate for Payer: Humana KY Medicaid |
$70.74
|
| Rate for Payer: Kentucky WC Medicaid |
$71.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.01
|
| Rate for Payer: Ohio Health Group HMO |
$154.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.76
|
| Rate for Payer: PHCS Commercial |
$197.46
|
| Rate for Payer: United Healthcare All Payer |
$181.01
|
|
|
SANDOSTATIN25MCG 500MCG 1MLAMP
|
Facility
|
IP
|
$205.69
|
|
|
Service Code
|
HCPCS J2354
|
| Hospital Charge Code |
25002266
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.74 |
| Max. Negotiated Rate |
$197.46 |
| Rate for Payer: Aetna Commercial |
$158.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.44
|
| Rate for Payer: Cash Price |
$102.84
|
| Rate for Payer: Cigna Commercial |
$170.72
|
| Rate for Payer: First Health Commercial |
$195.41
|
| Rate for Payer: Humana Commercial |
$174.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$181.01
|
| Rate for Payer: Ohio Health Group HMO |
$154.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$41.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.76
|
| Rate for Payer: PHCS Commercial |
$197.46
|
| Rate for Payer: United Healthcare All Payer |
$181.01
|
|
