|
SUBCUT REMOV SING/DUAL DEFIB G
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 33241
|
| Hospital Charge Code |
76101267
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SUBCUT REMOV SING/DUAL DEFIB G
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 33241
|
| Hospital Charge Code |
76101267
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.53 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$388.24
|
| Rate for Payer: Anthem Medicaid |
$155.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$378.33
|
| Rate for Payer: Healthspan PPO |
$381.72
|
| Rate for Payer: Humana Medicaid |
$155.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$316.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$158.64
|
| Rate for Payer: Molina Healthcare Passport |
$155.53
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.09
|
|
|
SUBCUT REMOV SING/DUAL DEFIB G
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 33241
|
| Hospital Charge Code |
761P1267
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$155.53 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Aetna Commercial |
$388.24
|
| Rate for Payer: Anthem Medicaid |
$155.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$378.33
|
| Rate for Payer: Healthspan PPO |
$381.72
|
| Rate for Payer: Humana Medicaid |
$155.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$316.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$158.64
|
| Rate for Payer: Molina Healthcare Passport |
$155.53
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$385.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.09
|
|
|
SUBCUT REMOV SING/DUAL DEFIB G
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 33241
|
| Hospital Charge Code |
76101267
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$4,754.25 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,395.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,754.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,584.45
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Humana Medicare Advantage |
$3,395.89
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,075.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SUBLATIVE FULL FACE LASER TX
|
Professional
|
Both
|
$400.00
|
|
| Hospital Charge Code |
22200169
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$140.00 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| 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
|
|
|
SUBLATIVE LIMIT FACE LSR TX
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200171
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
SUBLATIVE LMTD FACLSR-PP#1 50%
|
Professional
|
Both
|
$319.00
|
|
| Hospital Charge Code |
22200335
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$319.00
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$223.30
|
| Rate for Payer: UHCCP Medicaid |
$111.65
|
|
|
SUBLATIVE LOWREYELIDS LASTX
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200170
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$250.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$250.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
SUBLATIVE LOWREYELIDS-PP#1 50%
|
Professional
|
Both
|
$319.00
|
|
| Hospital Charge Code |
22200334
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$111.65 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$319.00
|
| Rate for Payer: Cash Price |
$159.50
|
| Rate for Payer: Multiplan PHCS |
$191.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$223.30
|
| Rate for Payer: UHCCP Medicaid |
$111.65
|
|
|
SUBLATVE FULFCE LSR PP#2/3 25%
|
Professional
|
Both
|
$255.00
|
|
| Hospital Charge Code |
22200450
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$89.25 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$255.00
|
| Rate for Payer: Cash Price |
$127.50
|
| Rate for Payer: Multiplan PHCS |
$153.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$178.50
|
| Rate for Payer: UHCCP Medicaid |
$89.25
|
|
|
SUBLATVE FULFCE LSRTX PP#1 50%
|
Professional
|
Both
|
$510.00
|
|
| Hospital Charge Code |
22200333
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$510.00
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Multiplan PHCS |
$306.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$357.00
|
| Rate for Payer: UHCCP Medicaid |
$178.50
|
|
|
SUBLIMAZE 0.1 MG (1MG/20ML)
|
Facility
|
IP
|
$82.76
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna Commercial |
$63.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64.55
|
| Rate for Payer: Cash Price |
$41.38
|
| Rate for Payer: Cigna Commercial |
$68.69
|
| Rate for Payer: First Health Commercial |
$78.62
|
| Rate for Payer: Humana Commercial |
$70.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.83
|
| Rate for Payer: Ohio Health Group HMO |
$62.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.66
|
| Rate for Payer: PHCS Commercial |
$79.45
|
| Rate for Payer: United Healthcare All Payer |
$72.83
|
|
|
SUBLIMAZE 0.1 MG (1MG/20ML)
|
Facility
|
OP
|
$82.76
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$79.45 |
| Rate for Payer: Aetna Commercial |
$63.73
|
| Rate for Payer: Anthem Medicaid |
$28.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64.55
|
| Rate for Payer: Cash Price |
$41.38
|
| Rate for Payer: Cigna Commercial |
$68.69
|
| Rate for Payer: First Health Commercial |
$78.62
|
| Rate for Payer: Humana Commercial |
$70.35
|
| Rate for Payer: Humana KY Medicaid |
$28.46
|
| Rate for Payer: Kentucky WC Medicaid |
$28.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$72.83
|
| Rate for Payer: Ohio Health Group HMO |
$62.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25.66
|
| Rate for Payer: PHCS Commercial |
$79.45
|
| Rate for Payer: United Healthcare All Payer |
$72.83
|
|
|
SUBLIMAZE 100 MCG (250MCG/5ML)
|
Facility
|
IP
|
$70.75
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$67.92 |
| Rate for Payer: Aetna Commercial |
$54.48
|
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.62
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cash Price |
$35.38
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: Cigna Commercial |
$58.72
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: First Health Commercial |
$67.21
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Humana Commercial |
$60.14
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Group HMO |
$53.06
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.49
|
| Rate for Payer: PHCS Commercial |
$67.92
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
| Rate for Payer: United Healthcare All Payer |
$62.26
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
|
|
SUBLIMAZE 100 MCG (250MCG/5ML)
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$74.88 |
| Rate for Payer: Aetna Commercial |
$60.06
|
| Rate for Payer: Aetna Commercial |
$54.48
|
| Rate for Payer: Aetna Commercial |
$60.83
|
| Rate for Payer: Anthem Medicaid |
$27.17
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem Medicaid |
$24.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.18
|
| Rate for Payer: Cash Price |
$39.50
|
| Rate for Payer: Cash Price |
$35.38
|
| Rate for Payer: Cash Price |
$39.00
|
| Rate for Payer: Cigna Commercial |
$64.74
|
| Rate for Payer: Cigna Commercial |
$58.72
|
| Rate for Payer: Cigna Commercial |
$65.57
|
| Rate for Payer: First Health Commercial |
$75.05
|
| Rate for Payer: First Health Commercial |
$67.21
|
| Rate for Payer: First Health Commercial |
$74.10
|
| Rate for Payer: Humana Commercial |
$67.15
|
| Rate for Payer: Humana Commercial |
$60.14
|
| Rate for Payer: Humana Commercial |
$66.30
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Humana KY Medicaid |
$24.33
|
| Rate for Payer: Humana KY Medicaid |
$27.17
|
| Rate for Payer: Kentucky WC Medicaid |
$27.44
|
| Rate for Payer: Kentucky WC Medicaid |
$27.10
|
| Rate for Payer: Kentucky WC Medicaid |
$24.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$69.52
|
| Rate for Payer: Ohio Health Group HMO |
$59.25
|
| Rate for Payer: Ohio Health Group HMO |
$53.06
|
| Rate for Payer: Ohio Health Group HMO |
$58.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.49
|
| Rate for Payer: PHCS Commercial |
$67.92
|
| Rate for Payer: PHCS Commercial |
$75.84
|
| Rate for Payer: PHCS Commercial |
$74.88
|
| Rate for Payer: United Healthcare All Payer |
$69.52
|
| Rate for Payer: United Healthcare All Payer |
$68.64
|
| Rate for Payer: United Healthcare All Payer |
$62.26
|
|
|
SUBLIMAZE 100 MCG/2ML AMPUL
|
Facility
|
OP
|
$74.54
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002377
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$71.56 |
| Rate for Payer: Aetna Commercial |
$57.40
|
| Rate for Payer: Aetna Commercial |
$58.94
|
| Rate for Payer: Anthem Medicaid |
$25.63
|
| Rate for Payer: Anthem Medicaid |
$26.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.70
|
| Rate for Payer: Cash Price |
$37.27
|
| Rate for Payer: Cash Price |
$38.27
|
| Rate for Payer: Cigna Commercial |
$63.53
|
| Rate for Payer: Cigna Commercial |
$61.87
|
| Rate for Payer: First Health Commercial |
$72.71
|
| Rate for Payer: First Health Commercial |
$70.81
|
| Rate for Payer: Humana Commercial |
$63.36
|
| Rate for Payer: Humana Commercial |
$65.06
|
| Rate for Payer: Humana KY Medicaid |
$25.63
|
| Rate for Payer: Humana KY Medicaid |
$26.32
|
| Rate for Payer: Kentucky WC Medicaid |
$26.59
|
| Rate for Payer: Kentucky WC Medicaid |
$25.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.36
|
| Rate for Payer: Ohio Health Group HMO |
$55.90
|
| Rate for Payer: Ohio Health Group HMO |
$57.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.73
|
| Rate for Payer: PHCS Commercial |
$73.48
|
| Rate for Payer: PHCS Commercial |
$71.56
|
| Rate for Payer: United Healthcare All Payer |
$67.36
|
| Rate for Payer: United Healthcare All Payer |
$65.60
|
|
|
SUBLIMAZE 100 MCG/2ML AMPUL
|
Facility
|
IP
|
$74.54
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25002377
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.69 |
| Max. Negotiated Rate |
$71.56 |
| Rate for Payer: Aetna Commercial |
$57.40
|
| Rate for Payer: Aetna Commercial |
$58.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$59.70
|
| Rate for Payer: Cash Price |
$37.27
|
| Rate for Payer: Cash Price |
$38.27
|
| Rate for Payer: Cigna Commercial |
$61.87
|
| Rate for Payer: Cigna Commercial |
$63.53
|
| Rate for Payer: First Health Commercial |
$72.71
|
| Rate for Payer: First Health Commercial |
$70.81
|
| Rate for Payer: Humana Commercial |
$65.06
|
| Rate for Payer: Humana Commercial |
$63.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$62.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$56.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$67.36
|
| Rate for Payer: Ohio Health Group HMO |
$55.90
|
| Rate for Payer: Ohio Health Group HMO |
$57.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.11
|
| Rate for Payer: PHCS Commercial |
$71.56
|
| Rate for Payer: PHCS Commercial |
$73.48
|
| Rate for Payer: United Healthcare All Payer |
$65.60
|
| Rate for Payer: United Healthcare All Payer |
$67.36
|
|
|
SUBLIMAZE 1MG/100 ML/NS DRIP
|
Facility
|
OP
|
$102.80
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25003500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$98.69 |
| Rate for Payer: Aetna Commercial |
$79.16
|
| Rate for Payer: Anthem Medicaid |
$35.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.18
|
| Rate for Payer: Cash Price |
$51.40
|
| Rate for Payer: Cigna Commercial |
$85.32
|
| Rate for Payer: First Health Commercial |
$97.66
|
| Rate for Payer: Humana Commercial |
$87.38
|
| Rate for Payer: Humana KY Medicaid |
$35.35
|
| Rate for Payer: Kentucky WC Medicaid |
$35.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$90.46
|
| Rate for Payer: Ohio Health Group HMO |
$77.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.87
|
| Rate for Payer: PHCS Commercial |
$98.69
|
| Rate for Payer: United Healthcare All Payer |
$90.46
|
|
|
SUBLIMAZE 1MG/100 ML/NS DRIP
|
Facility
|
IP
|
$102.80
|
|
|
Service Code
|
HCPCS J3010
|
| Hospital Charge Code |
25003500
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.36 |
| Max. Negotiated Rate |
$98.69 |
| Rate for Payer: Aetna Commercial |
$79.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.18
|
| Rate for Payer: Cash Price |
$51.40
|
| Rate for Payer: Cigna Commercial |
$85.32
|
| Rate for Payer: First Health Commercial |
$97.66
|
| Rate for Payer: Humana Commercial |
$87.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$84.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$75.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$90.46
|
| Rate for Payer: Ohio Health Group HMO |
$77.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.87
|
| Rate for Payer: PHCS Commercial |
$98.69
|
| Rate for Payer: United Healthcare All Payer |
$90.46
|
|
|
SUBLIME FACE/NECK LASER TX
|
Professional
|
Both
|
$350.00
|
|
| Hospital Charge Code |
22200177
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
|
|
SUBLIME FACE/NECK LSR PP#1 50%
|
Professional
|
Both
|
$446.00
|
|
| Hospital Charge Code |
22200341
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$156.10 |
| Max. Negotiated Rate |
$446.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$446.00
|
| Rate for Payer: Cash Price |
$223.00
|
| Rate for Payer: Multiplan PHCS |
$267.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.20
|
| Rate for Payer: UHCCP Medicaid |
$156.10
|
|
|
SUBLIME FCE/NEC LSR PP#2/3 25%
|
Professional
|
Both
|
$223.00
|
|
| Hospital Charge Code |
22200457
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$223.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$223.00
|
| Rate for Payer: Cash Price |
$111.50
|
| Rate for Payer: Multiplan PHCS |
$133.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$156.10
|
| Rate for Payer: UHCCP Medicaid |
$78.05
|
|
|
SUBLI NASOLA CHE JOWL LASTX
|
Professional
|
Both
|
$325.00
|
|
| Hospital Charge Code |
22200176
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$113.75 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$325.00
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Multiplan PHCS |
$195.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$227.50
|
| Rate for Payer: UHCCP Medicaid |
$113.75
|
|
|
SUBLI NASOLACHE JOWL PP#1 50%
|
Professional
|
Both
|
$414.00
|
|
| Hospital Charge Code |
22200340
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$144.90 |
| Max. Negotiated Rate |
$414.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$414.00
|
| Rate for Payer: Cash Price |
$207.00
|
| Rate for Payer: Multiplan PHCS |
$248.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$289.80
|
| Rate for Payer: UHCCP Medicaid |
$144.90
|
|
|
SUBLI NASOLACHE JWL PP#2/3 25%
|
Professional
|
Both
|
$207.00
|
|
| Hospital Charge Code |
22200456
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$72.45 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$207.00
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Multiplan PHCS |
$124.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$144.90
|
| Rate for Payer: UHCCP Medicaid |
$72.45
|
|
