|
TX MISSED ABORT 2ND TRIMESTE(P
|
Professional
|
Both
|
$1,050.00
|
|
|
Service Code
|
HCPCS 59821
|
| Hospital Charge Code |
720P0029
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$194.66 |
| Max. Negotiated Rate |
$630.00 |
| Rate for Payer: Aetna Commercial |
$564.78
|
| Rate for Payer: Ambetter Exchange |
$358.47
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$194.66
|
| Rate for Payer: Anthem Medicaid |
$213.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$358.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$358.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$430.16
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cash Price |
$525.00
|
| Rate for Payer: Cigna Commercial |
$521.41
|
| Rate for Payer: Healthspan PPO |
$438.89
|
| Rate for Payer: Humana Medicaid |
$213.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$469.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$358.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$358.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$217.28
|
| Rate for Payer: Molina Healthcare Passport |
$213.02
|
| Rate for Payer: Multiplan PHCS |
$630.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$466.01
|
| Rate for Payer: UHCCP Medicaid |
$204.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$215.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$358.47
|
|
|
TX MISSED ABORT 2ND TRIMESTER
|
Facility
|
OP
|
$6,431.00
|
|
|
Service Code
|
HCPCS 59821
|
| Hospital Charge Code |
72000029
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$2,211.62 |
| Max. Negotiated Rate |
$6,173.76 |
| Rate for Payer: Aetna Commercial |
$4,951.87
|
| Rate for Payer: Anthem Medicaid |
$2,211.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,016.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$3,215.50
|
| Rate for Payer: Cash Price |
$3,215.50
|
| Rate for Payer: Cigna Commercial |
$5,337.73
|
| Rate for Payer: First Health Commercial |
$6,109.45
|
| Rate for Payer: Humana Commercial |
$5,466.35
|
| Rate for Payer: Humana KY Medicaid |
$2,211.62
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$2,234.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,273.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,746.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,255.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,659.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,823.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,594.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,437.39
|
| Rate for Payer: PHCS Commercial |
$6,173.76
|
| Rate for Payer: United Healthcare All Payer |
$5,659.28
|
|
|
TX MISSED ABORT 2ND TRIMESTER
|
Professional
|
Both
|
$6,431.00
|
|
|
Service Code
|
HCPCS 59821
|
| Hospital Charge Code |
72000029
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$194.66 |
| Max. Negotiated Rate |
$3,858.60 |
| Rate for Payer: Aetna Commercial |
$564.78
|
| Rate for Payer: Ambetter Exchange |
$358.47
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$194.66
|
| Rate for Payer: Anthem Medicaid |
$213.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$358.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$358.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$430.16
|
| Rate for Payer: Cash Price |
$3,215.50
|
| Rate for Payer: Cash Price |
$3,215.50
|
| Rate for Payer: Cigna Commercial |
$521.41
|
| Rate for Payer: Healthspan PPO |
$438.89
|
| Rate for Payer: Humana Medicaid |
$213.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$469.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$358.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$358.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$217.28
|
| Rate for Payer: Molina Healthcare Passport |
$213.02
|
| Rate for Payer: Multiplan PHCS |
$3,858.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$466.01
|
| Rate for Payer: UHCCP Medicaid |
$204.39
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$215.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$358.47
|
|
|
TX MISSED ABORT 2ND TRIMESTER
|
Facility
|
IP
|
$6,431.00
|
|
|
Service Code
|
HCPCS 59821
|
| Hospital Charge Code |
72000029
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,929.30 |
| Max. Negotiated Rate |
$6,173.76 |
| Rate for Payer: Aetna Commercial |
$4,951.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,016.18
|
| Rate for Payer: Cash Price |
$3,215.50
|
| Rate for Payer: Cigna Commercial |
$5,337.73
|
| Rate for Payer: First Health Commercial |
$6,109.45
|
| Rate for Payer: Humana Commercial |
$5,466.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,273.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,746.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,929.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,659.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,823.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,144.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,594.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,437.39
|
| Rate for Payer: PHCS Commercial |
$6,173.76
|
| Rate for Payer: United Healthcare All Payer |
$5,659.28
|
|
|
TX MISSED ABORT 2ND TRIMESTE(T
|
Facility
|
OP
|
$5,381.00
|
|
|
Service Code
|
HCPCS 59821
|
| Hospital Charge Code |
720T0029
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,850.53 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$4,143.37
|
| Rate for Payer: Anthem Medicaid |
$1,850.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,197.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$2,690.50
|
| Rate for Payer: Cash Price |
$2,690.50
|
| Rate for Payer: Cigna Commercial |
$4,466.23
|
| Rate for Payer: First Health Commercial |
$5,111.95
|
| Rate for Payer: Humana Commercial |
$4,573.85
|
| Rate for Payer: Humana KY Medicaid |
$1,850.53
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,869.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,412.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,971.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,887.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,735.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,035.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,304.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,681.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,712.89
|
| Rate for Payer: PHCS Commercial |
$5,165.76
|
| Rate for Payer: United Healthcare All Payer |
$4,735.28
|
|
|
TX MISSED ABORT 2ND TRIMESTE(T
|
Facility
|
IP
|
$5,381.00
|
|
|
Service Code
|
HCPCS 59821
|
| Hospital Charge Code |
720T0029
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,614.30 |
| Max. Negotiated Rate |
$5,165.76 |
| Rate for Payer: Aetna Commercial |
$4,143.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,197.18
|
| Rate for Payer: Cash Price |
$2,690.50
|
| Rate for Payer: Cigna Commercial |
$4,466.23
|
| Rate for Payer: First Health Commercial |
$5,111.95
|
| Rate for Payer: Humana Commercial |
$4,573.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,412.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,971.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,614.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,735.28
|
| Rate for Payer: Ohio Health Group HMO |
$4,035.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,304.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,681.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,712.89
|
| Rate for Payer: PHCS Commercial |
$5,165.76
|
| Rate for Payer: United Healthcare All Payer |
$4,735.28
|
|
|
TX OF CLSD ELBOW DISLOCATION
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
HCPCS 24640
|
| Hospital Charge Code |
45000124
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$244.50 |
| Max. Negotiated Rate |
$782.40 |
| Rate for Payer: Aetna Commercial |
$627.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$635.70
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cigna Commercial |
$676.45
|
| Rate for Payer: First Health Commercial |
$774.25
|
| Rate for Payer: Humana Commercial |
$692.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.20
|
| Rate for Payer: Ohio Health Group HMO |
$611.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$652.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.35
|
| Rate for Payer: PHCS Commercial |
$782.40
|
| Rate for Payer: United Healthcare All Payer |
$717.20
|
|
|
TX OF CLSD ELBOW DISLOCATION
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
HCPCS 24640
|
| Hospital Charge Code |
45000124
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$782.40 |
| Rate for Payer: Aetna Commercial |
$627.55
|
| Rate for Payer: Anthem Medicaid |
$280.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$635.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cigna Commercial |
$676.45
|
| Rate for Payer: First Health Commercial |
$774.25
|
| Rate for Payer: Humana Commercial |
$692.75
|
| Rate for Payer: Humana KY Medicaid |
$280.28
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$283.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$285.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.20
|
| Rate for Payer: Ohio Health Group HMO |
$611.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$652.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.35
|
| Rate for Payer: PHCS Commercial |
$782.40
|
| Rate for Payer: United Healthcare All Payer |
$717.20
|
|
|
TX/PRO/DX INJ NEW DRUG ADDON
|
Professional
|
Both
|
$222.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000023
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$13.29 |
| Max. Negotiated Rate |
$133.20 |
| Rate for Payer: Aetna Commercial |
$36.45
|
| Rate for Payer: Ambetter Exchange |
$13.29
|
| Rate for Payer: Anthem Medicaid |
$18.99
|
| Rate for Payer: Buckeye Individual/Medicaid |
$13.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$13.29
|
| Rate for Payer: CareSource Just4Me Medicare |
$15.95
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$32.03
|
| Rate for Payer: Healthspan PPO |
$34.16
|
| Rate for Payer: Humana Medicaid |
$18.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$28.83
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$13.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.29
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$19.37
|
| Rate for Payer: Molina Healthcare Passport |
$18.99
|
| Rate for Payer: Multiplan PHCS |
$133.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.28
|
| Rate for Payer: UHCCP Medicaid |
$77.70
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$19.18
|
| Rate for Payer: Wellcare Medicare Advantage |
$13.29
|
|
|
TX/PRO/DX INJ NEW DRUG ADDON
|
Facility
|
OP
|
$222.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000023
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$213.12 |
| Rate for Payer: Aetna Commercial |
$170.94
|
| Rate for Payer: Anthem Medicaid |
$76.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$42.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$173.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$59.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.55
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$184.26
|
| Rate for Payer: First Health Commercial |
$210.90
|
| Rate for Payer: Humana Commercial |
$188.70
|
| Rate for Payer: Humana KY Medicaid |
$76.35
|
| Rate for Payer: Humana Medicare Advantage |
$42.63
|
| Rate for Payer: Kentucky WC Medicaid |
$77.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$182.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$77.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$195.36
|
| Rate for Payer: Ohio Health Group HMO |
$166.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$177.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$193.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.18
|
| Rate for Payer: PHCS Commercial |
$213.12
|
| Rate for Payer: United Healthcare All Payer |
$195.36
|
|
|
TX/PRO/DX INJ NEW DRUG ADDON
|
Facility
|
IP
|
$222.00
|
|
|
Service Code
|
HCPCS 96375
|
| Hospital Charge Code |
26000023
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$213.12 |
| Rate for Payer: Aetna Commercial |
$170.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$173.16
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna Commercial |
$184.26
|
| Rate for Payer: First Health Commercial |
$210.90
|
| Rate for Payer: Humana Commercial |
$188.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$182.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$163.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$66.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$195.36
|
| Rate for Payer: Ohio Health Group HMO |
$166.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$177.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$193.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$153.18
|
| Rate for Payer: PHCS Commercial |
$213.12
|
| Rate for Payer: United Healthcare All Payer |
$195.36
|
|
|
TX/PRO/DX INJ SAME DRUG ADON
|
Facility
|
IP
|
$184.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
26000024
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$55.20 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$141.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: First Health Commercial |
$174.80
|
| Rate for Payer: Humana Commercial |
$156.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.92
|
| Rate for Payer: Ohio Health Group HMO |
$138.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.96
|
| Rate for Payer: PHCS Commercial |
$176.64
|
| Rate for Payer: United Healthcare All Payer |
$161.92
|
|
|
TX/PRO/DX INJ SAME DRUG ADON
|
Facility
|
OP
|
$184.00
|
|
|
Service Code
|
HCPCS 96376
|
| Hospital Charge Code |
26000024
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$55.20 |
| Max. Negotiated Rate |
$176.64 |
| Rate for Payer: Aetna Commercial |
$141.68
|
| Rate for Payer: Anthem Medicaid |
$63.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.52
|
| Rate for Payer: Cash Price |
$92.00
|
| Rate for Payer: Cigna Commercial |
$152.72
|
| Rate for Payer: First Health Commercial |
$174.80
|
| Rate for Payer: Humana Commercial |
$156.40
|
| Rate for Payer: Humana KY Medicaid |
$63.28
|
| Rate for Payer: Kentucky WC Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.92
|
| Rate for Payer: Ohio Health Group HMO |
$138.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.96
|
| Rate for Payer: PHCS Commercial |
$176.64
|
| Rate for Payer: United Healthcare All Payer |
$161.92
|
|
|
TX TIBSHFT FX IMD IMP &/CERCLA
|
Facility
|
OP
|
$2,006.00
|
|
|
Service Code
|
HCPCS 27759
|
| Hospital Charge Code |
76100927
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$689.86 |
| Max. Negotiated Rate |
$16,644.15 |
| Rate for Payer: Aetna Commercial |
$1,544.62
|
| Rate for Payer: Anthem Medicaid |
$689.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11,888.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,564.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16,644.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$16,049.72
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cigna Commercial |
$1,664.98
|
| Rate for Payer: First Health Commercial |
$1,905.70
|
| Rate for Payer: Humana Commercial |
$1,705.10
|
| Rate for Payer: Humana KY Medicaid |
$689.86
|
| Rate for Payer: Humana Medicare Advantage |
$11,888.68
|
| Rate for Payer: Kentucky WC Medicaid |
$696.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,644.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,480.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14,266.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$703.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,765.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,504.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,745.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,384.14
|
| Rate for Payer: PHCS Commercial |
$1,925.76
|
| Rate for Payer: United Healthcare All Payer |
$1,765.28
|
|
|
TX TIBSHFT FX IMD IMP &/CERCLA
|
Professional
|
Both
|
$2,006.00
|
|
|
Service Code
|
HCPCS 27759
|
| Hospital Charge Code |
76100927
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$702.10 |
| Max. Negotiated Rate |
$1,630.43 |
| Rate for Payer: Aetna Commercial |
$1,496.64
|
| Rate for Payer: Ambetter Exchange |
$948.64
|
| Rate for Payer: Anthem Medicaid |
$792.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$948.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$948.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,138.37
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cigna Commercial |
$1,630.43
|
| Rate for Payer: Healthspan PPO |
$1,355.63
|
| Rate for Payer: Humana Medicaid |
$792.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,250.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$948.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$808.05
|
| Rate for Payer: Molina Healthcare Passport |
$792.21
|
| Rate for Payer: Multiplan PHCS |
$1,203.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,233.23
|
| Rate for Payer: UHCCP Medicaid |
$702.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$800.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$948.64
|
|
|
TX TIBSHFT FX IMD IMP &/CERCLA
|
Professional
|
Both
|
$2,006.00
|
|
|
Service Code
|
HCPCS 27759
|
| Hospital Charge Code |
761P0927
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$702.10 |
| Max. Negotiated Rate |
$1,630.43 |
| Rate for Payer: Aetna Commercial |
$1,496.64
|
| Rate for Payer: Ambetter Exchange |
$948.64
|
| Rate for Payer: Anthem Medicaid |
$792.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$948.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$948.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,138.37
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cigna Commercial |
$1,630.43
|
| Rate for Payer: Healthspan PPO |
$1,355.63
|
| Rate for Payer: Humana Medicaid |
$792.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,250.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$948.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$948.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$808.05
|
| Rate for Payer: Molina Healthcare Passport |
$792.21
|
| Rate for Payer: Multiplan PHCS |
$1,203.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,233.23
|
| Rate for Payer: UHCCP Medicaid |
$702.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$800.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$948.64
|
|
|
TX TIBSHFT FX IMD IMP &/CERCLA
|
Facility
|
IP
|
$2,006.00
|
|
|
Service Code
|
HCPCS 27759
|
| Hospital Charge Code |
76100927
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$601.80 |
| Max. Negotiated Rate |
$1,925.76 |
| Rate for Payer: Aetna Commercial |
$1,544.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,564.68
|
| Rate for Payer: Cash Price |
$1,003.00
|
| Rate for Payer: Cigna Commercial |
$1,664.98
|
| Rate for Payer: First Health Commercial |
$1,905.70
|
| Rate for Payer: Humana Commercial |
$1,705.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,644.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,480.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$601.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,765.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,504.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,604.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,745.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,384.14
|
| Rate for Payer: PHCS Commercial |
$1,925.76
|
| Rate for Payer: United Healthcare All Payer |
$1,765.28
|
|
|
TYLENOL 325MG SUPPOSITORY
|
Facility
|
OP
|
$9.02
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
25001610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.04
|
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cigna Commercial |
$7.49
|
| Rate for Payer: First Health Commercial |
$8.57
|
| Rate for Payer: Humana Commercial |
$7.67
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.94
|
| Rate for Payer: Ohio Health Group HMO |
$6.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.22
|
| Rate for Payer: PHCS Commercial |
$8.66
|
| Rate for Payer: United Healthcare All Payer |
$7.94
|
|
|
TYLENOL 325MG SUPPOSITORY
|
Facility
|
IP
|
$9.02
|
|
|
Service Code
|
NDC 51672211602
|
| Hospital Charge Code |
25001610
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.66 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.04
|
| Rate for Payer: Cash Price |
$4.51
|
| Rate for Payer: Cigna Commercial |
$7.49
|
| Rate for Payer: First Health Commercial |
$8.57
|
| Rate for Payer: Humana Commercial |
$7.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.94
|
| Rate for Payer: Ohio Health Group HMO |
$6.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.22
|
| Rate for Payer: PHCS Commercial |
$8.66
|
| Rate for Payer: United Healthcare All Payer |
$7.94
|
|
|
TYLENOL (ACETAMIN) 325MG/1TAB
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
25001798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
TYLENOL (ACETAMIN) 325MG/1TAB
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 904677361
|
| Hospital Charge Code |
25001798
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.03
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
TYLENOL(ACETAMIN) 65 650MG/1EA
|
Facility
|
IP
|
$4.40
|
|
|
Service Code
|
NDC 45802073033
|
| Hospital Charge Code |
25001617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
TYLENOL(ACETAMIN) 65 650MG/1EA
|
Facility
|
OP
|
$4.40
|
|
|
Service Code
|
NDC 45802073033
|
| Hospital Charge Code |
25001617
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.22 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.43
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.65
|
| Rate for Payer: First Health Commercial |
$4.18
|
| Rate for Payer: Humana Commercial |
$3.74
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.87
|
| Rate for Payer: Ohio Health Group HMO |
$3.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.04
|
| Rate for Payer: PHCS Commercial |
$4.22
|
| Rate for Payer: United Healthcare All Payer |
$3.87
|
|
|
TYLENOL(ACETAMINO 650MG/20.3ML
|
Facility
|
IP
|
$10.03
|
|
|
Service Code
|
NDC 121197100
|
| Hospital Charge Code |
25001618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna Commercial |
$7.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.82
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.32
|
| Rate for Payer: First Health Commercial |
$9.53
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.83
|
| Rate for Payer: Ohio Health Group HMO |
$7.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.92
|
| Rate for Payer: PHCS Commercial |
$9.63
|
| Rate for Payer: United Healthcare All Payer |
$8.83
|
|
|
TYLENOL(ACETAMINO 650MG/20.3ML
|
Facility
|
OP
|
$10.03
|
|
|
Service Code
|
NDC 121197100
|
| Hospital Charge Code |
25001618
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.63 |
| Rate for Payer: Aetna Commercial |
$7.72
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.82
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.32
|
| Rate for Payer: First Health Commercial |
$9.53
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.83
|
| Rate for Payer: Ohio Health Group HMO |
$7.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.92
|
| Rate for Payer: PHCS Commercial |
$9.63
|
| Rate for Payer: United Healthcare All Payer |
$8.83
|
|
