|
DESIGN MLC DEVICE FOR IMRT(T
|
Facility
|
OP
|
$1,763.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
333T0018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$229.19 |
| Max. Negotiated Rate |
$1,692.48 |
| Rate for Payer: Aetna Commercial |
$1,357.51
|
| Rate for Payer: Anthem Medicaid |
$606.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$319.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,375.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$447.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$431.35
|
| Rate for Payer: Cash Price |
$881.50
|
| Rate for Payer: Cash Price |
$881.50
|
| Rate for Payer: Cigna Commercial |
$1,463.29
|
| Rate for Payer: First Health Commercial |
$1,674.85
|
| Rate for Payer: Humana Commercial |
$1,498.55
|
| Rate for Payer: Humana KY Medicaid |
$606.30
|
| Rate for Payer: Humana Medicare Advantage |
$319.52
|
| Rate for Payer: Kentucky WC Medicaid |
$612.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,445.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,301.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$383.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$618.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,551.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,322.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$546.53
|
| Rate for Payer: PHCS Commercial |
$1,692.48
|
| Rate for Payer: United Healthcare All Payer |
$1,551.44
|
|
|
DESIGN MLC DEVICE FOR IMRT(T
|
Facility
|
IP
|
$1,763.00
|
|
|
Service Code
|
HCPCS 77338
|
| Hospital Charge Code |
333T0018
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$229.19 |
| Max. Negotiated Rate |
$1,692.48 |
| Rate for Payer: Aetna Commercial |
$1,357.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,375.14
|
| Rate for Payer: Cash Price |
$881.50
|
| Rate for Payer: Cigna Commercial |
$1,463.29
|
| Rate for Payer: First Health Commercial |
$1,674.85
|
| Rate for Payer: Humana Commercial |
$1,498.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,445.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,301.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$528.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,551.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,322.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$546.53
|
| Rate for Payer: PHCS Commercial |
$1,692.48
|
| Rate for Payer: United Healthcare All Payer |
$1,551.44
|
|
|
DESIPRAMINE 10MG TABLET
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 69238105301
|
| Hospital Charge Code |
25002987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
DESIPRAMINE 10MG TABLET
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 69238105301
|
| Hospital Charge Code |
25002987
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
DESIPRAMINE 25MG TABLET
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 50742011301
|
| Hospital Charge Code |
25000540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
DESIPRAMINE 25MG TABLET
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 50742011301
|
| Hospital Charge Code |
25000540
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
DESITIN OINT 2 OZ.
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 74300000070
|
| Hospital Charge Code |
25000541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
DESITIN OINT 2 OZ.
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 74300000070
|
| Hospital Charge Code |
25000541
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
DES LESIOPALAT ULVULA CRYOCHM
|
Facility
|
IP
|
$3,752.00
|
|
|
Service Code
|
HCPCS 42160
|
| Hospital Charge Code |
76101675
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$487.76 |
| Max. Negotiated Rate |
$3,601.92 |
| Rate for Payer: Aetna Commercial |
$2,889.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,926.56
|
| Rate for Payer: Cash Price |
$1,876.00
|
| Rate for Payer: Cigna Commercial |
$3,114.16
|
| Rate for Payer: First Health Commercial |
$3,564.40
|
| Rate for Payer: Humana Commercial |
$3,189.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,076.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,768.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,125.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,301.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,814.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$750.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$487.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,163.12
|
| Rate for Payer: PHCS Commercial |
$3,601.92
|
| Rate for Payer: United Healthcare All Payer |
$3,301.76
|
|
|
DES LESIOPALAT ULVULA CRYOCHM
|
Facility
|
OP
|
$3,912.00
|
|
|
Service Code
|
HCPCS 42160
|
| Hospital Charge Code |
45000257
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$508.56 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Aetna Commercial |
$3,012.24
|
| Rate for Payer: Anthem Medicaid |
$1,345.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$1,956.00
|
| Rate for Payer: Cash Price |
$1,956.00
|
| Rate for Payer: Cigna Commercial |
$3,246.96
|
| Rate for Payer: First Health Commercial |
$3,716.40
|
| Rate for Payer: Humana Commercial |
$3,325.20
|
| Rate for Payer: Humana KY Medicaid |
$1,345.34
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,359.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,207.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,372.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$782.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,212.72
|
| Rate for Payer: PHCS Commercial |
$3,755.52
|
| Rate for Payer: United Healthcare All Payer |
$3,442.56
|
|
|
DES LESIOPALAT ULVULA CRYOCHM
|
Facility
|
IP
|
$3,912.00
|
|
|
Service Code
|
HCPCS 42160
|
| Hospital Charge Code |
45000257
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$508.56 |
| Max. Negotiated Rate |
$3,755.52 |
| Rate for Payer: Aetna Commercial |
$3,012.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,051.36
|
| Rate for Payer: Cash Price |
$1,956.00
|
| Rate for Payer: Cigna Commercial |
$3,246.96
|
| Rate for Payer: First Health Commercial |
$3,716.40
|
| Rate for Payer: Humana Commercial |
$3,325.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,207.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,887.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,442.56
|
| Rate for Payer: Ohio Health Group HMO |
$2,934.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$782.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,212.72
|
| Rate for Payer: PHCS Commercial |
$3,755.52
|
| Rate for Payer: United Healthcare All Payer |
$3,442.56
|
|
|
DES LESIOPALAT ULVULA CRYOCHM
|
Facility
|
OP
|
$3,752.00
|
|
|
Service Code
|
HCPCS 42160
|
| Hospital Charge Code |
76101675
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$487.76 |
| Max. Negotiated Rate |
$3,897.84 |
| Rate for Payer: Molina Healthcare Medicaid |
$1,316.20
|
| Rate for Payer: Aetna Commercial |
$2,889.04
|
| Rate for Payer: Anthem Medicaid |
$1,290.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,926.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$1,876.00
|
| Rate for Payer: Cash Price |
$1,876.00
|
| Rate for Payer: Cigna Commercial |
$3,114.16
|
| Rate for Payer: First Health Commercial |
$3,564.40
|
| Rate for Payer: Humana Commercial |
$3,189.20
|
| Rate for Payer: Humana KY Medicaid |
$1,290.31
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,303.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,076.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,768.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,301.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,814.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$750.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$487.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,163.12
|
| Rate for Payer: PHCS Commercial |
$3,601.92
|
| Rate for Payer: United Healthcare All Payer |
$3,301.76
|
|
|
DES MAL LES 1.1-2CM FEENL
|
Facility
|
OP
|
$858.00
|
|
|
Service Code
|
HCPCS 17282
|
| Hospital Charge Code |
76100268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.54 |
| Max. Negotiated Rate |
$823.68 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Anthem Medicaid |
$295.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cigna Commercial |
$712.14
|
| Rate for Payer: First Health Commercial |
$815.10
|
| Rate for Payer: Humana Commercial |
$729.30
|
| Rate for Payer: Humana KY Medicaid |
$295.07
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$298.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$703.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$300.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.04
|
| Rate for Payer: Ohio Health Group HMO |
$643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$171.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$265.98
|
| Rate for Payer: PHCS Commercial |
$823.68
|
| Rate for Payer: United Healthcare All Payer |
$755.04
|
|
|
DES MAL LES 1.1-2CM FEENL
|
Facility
|
IP
|
$858.00
|
|
|
Service Code
|
HCPCS 17282
|
| Hospital Charge Code |
76100268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$111.54 |
| Max. Negotiated Rate |
$823.68 |
| Rate for Payer: Aetna Commercial |
$660.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.24
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cigna Commercial |
$712.14
|
| Rate for Payer: First Health Commercial |
$815.10
|
| Rate for Payer: Humana Commercial |
$729.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$703.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.04
|
| Rate for Payer: Ohio Health Group HMO |
$643.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$171.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$265.98
|
| Rate for Payer: PHCS Commercial |
$823.68
|
| Rate for Payer: United Healthcare All Payer |
$755.04
|
|
|
DES MAL LES 1.1-2CM FEENL
|
Professional
|
Both
|
$858.00
|
|
|
Service Code
|
HCPCS 17282
|
| Hospital Charge Code |
76100268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.54 |
| Max. Negotiated Rate |
$858.00 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.54
|
| Rate for Payer: Anthem Medicaid |
$98.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$858.00
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cash Price |
$429.00
|
| Rate for Payer: Cigna Commercial |
$246.64
|
| Rate for Payer: Healthspan PPO |
$223.33
|
| Rate for Payer: Humana Medicaid |
$98.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$100.42
|
| Rate for Payer: Molina Healthcare Passport |
$98.45
|
| Rate for Payer: Multiplan PHCS |
$514.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$600.60
|
| Rate for Payer: UHCCP Medicaid |
$98.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$99.43
|
|
|
DES MAL LES 1.1-2CM FEENL(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 17282
|
| Hospital Charge Code |
761P0268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$93.54 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna Commercial |
$203.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$93.54
|
| Rate for Payer: Anthem Medicaid |
$98.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$246.64
|
| Rate for Payer: Healthspan PPO |
$223.33
|
| Rate for Payer: Humana Medicaid |
$98.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$182.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$100.42
|
| Rate for Payer: Molina Healthcare Passport |
$98.45
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$98.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$99.43
|
|
|
DES MAL LES 1.1-2CM FEENL(T
|
Facility
|
IP
|
$458.00
|
|
|
Service Code
|
HCPCS 17282
|
| Hospital Charge Code |
761T0268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$439.68 |
| Rate for Payer: Aetna Commercial |
$352.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$357.24
|
| Rate for Payer: Cash Price |
$229.00
|
| Rate for Payer: Cigna Commercial |
$380.14
|
| Rate for Payer: First Health Commercial |
$435.10
|
| Rate for Payer: Humana Commercial |
$389.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$375.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$338.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$403.04
|
| Rate for Payer: Ohio Health Group HMO |
$343.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.98
|
| Rate for Payer: PHCS Commercial |
$439.68
|
| Rate for Payer: United Healthcare All Payer |
$403.04
|
|
|
DES MAL LES 1.1-2CM FEENL(T
|
Facility
|
OP
|
$458.00
|
|
|
Service Code
|
HCPCS 17282
|
| Hospital Charge Code |
761T0268
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$482.75 |
| Rate for Payer: Aetna Commercial |
$352.66
|
| Rate for Payer: Anthem Medicaid |
$157.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$357.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$229.00
|
| Rate for Payer: Cash Price |
$229.00
|
| Rate for Payer: Cigna Commercial |
$380.14
|
| Rate for Payer: First Health Commercial |
$435.10
|
| Rate for Payer: Humana Commercial |
$389.30
|
| Rate for Payer: Humana KY Medicaid |
$157.51
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$159.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$375.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$338.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$160.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$403.04
|
| Rate for Payer: Ohio Health Group HMO |
$343.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.98
|
| Rate for Payer: PHCS Commercial |
$439.68
|
| Rate for Payer: United Healthcare All Payer |
$403.04
|
|
|
DES MAL LES 1.1-2CM SNHF
|
Professional
|
Both
|
$672.00
|
|
|
Service Code
|
HCPCS 17272
|
| Hospital Charge Code |
76100262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.29 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$180.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$80.29
|
| Rate for Payer: Anthem Medicaid |
$84.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$672.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$222.55
|
| Rate for Payer: Healthspan PPO |
$203.02
|
| Rate for Payer: Humana Medicaid |
$84.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.28
|
| Rate for Payer: Molina Healthcare Passport |
$84.59
|
| Rate for Payer: Multiplan PHCS |
$403.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$470.40
|
| Rate for Payer: UHCCP Medicaid |
$84.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.44
|
|
|
DES MAL LES 1.1-2CM SNHF
|
Facility
|
IP
|
$672.00
|
|
|
Service Code
|
HCPCS 17272
|
| Hospital Charge Code |
76100262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.36 |
| Max. Negotiated Rate |
$645.12 |
| Rate for Payer: Aetna Commercial |
$517.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$524.16
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$557.76
|
| Rate for Payer: First Health Commercial |
$638.40
|
| Rate for Payer: Humana Commercial |
$571.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$551.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$495.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$201.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$591.36
|
| Rate for Payer: Ohio Health Group HMO |
$504.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$134.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$208.32
|
| Rate for Payer: PHCS Commercial |
$645.12
|
| Rate for Payer: United Healthcare All Payer |
$591.36
|
|
|
DES MAL LES 1.1-2CM SNHF
|
Facility
|
OP
|
$672.00
|
|
|
Service Code
|
HCPCS 17272
|
| Hospital Charge Code |
76100262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.36 |
| Max. Negotiated Rate |
$645.12 |
| Rate for Payer: Aetna Commercial |
$517.44
|
| Rate for Payer: Anthem Medicaid |
$231.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$524.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cash Price |
$336.00
|
| Rate for Payer: Cigna Commercial |
$557.76
|
| Rate for Payer: First Health Commercial |
$638.40
|
| Rate for Payer: Humana Commercial |
$571.20
|
| Rate for Payer: Humana KY Medicaid |
$231.10
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$233.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$551.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$495.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$235.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$591.36
|
| Rate for Payer: Ohio Health Group HMO |
$504.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$134.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$208.32
|
| Rate for Payer: PHCS Commercial |
$645.12
|
| Rate for Payer: United Healthcare All Payer |
$591.36
|
|
|
DES MAL LES 1.1-2CM SNHF(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 17272
|
| Hospital Charge Code |
761P0262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.29 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$180.04
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$80.29
|
| Rate for Payer: Anthem Medicaid |
$84.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$222.55
|
| Rate for Payer: Healthspan PPO |
$203.02
|
| Rate for Payer: Humana Medicaid |
$84.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$161.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$86.28
|
| Rate for Payer: Molina Healthcare Passport |
$84.59
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$84.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$85.44
|
|
|
DES MAL LES 1.1-2CM SNHF(T
|
Facility
|
IP
|
$322.00
|
|
|
Service Code
|
HCPCS 17272
|
| Hospital Charge Code |
761T0262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.86 |
| Max. Negotiated Rate |
$309.12 |
| Rate for Payer: Aetna Commercial |
$247.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.16
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cigna Commercial |
$267.26
|
| Rate for Payer: First Health Commercial |
$305.90
|
| Rate for Payer: Humana Commercial |
$273.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.36
|
| Rate for Payer: Ohio Health Group HMO |
$241.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.82
|
| Rate for Payer: PHCS Commercial |
$309.12
|
| Rate for Payer: United Healthcare All Payer |
$283.36
|
|
|
DES MAL LES 1.1-2CM SNHF(T
|
Facility
|
OP
|
$322.00
|
|
|
Service Code
|
HCPCS 17272
|
| Hospital Charge Code |
761T0262
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.86 |
| Max. Negotiated Rate |
$309.12 |
| Rate for Payer: Aetna Commercial |
$247.94
|
| Rate for Payer: Anthem Medicaid |
$110.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$173.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$251.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$242.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$233.71
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cigna Commercial |
$267.26
|
| Rate for Payer: First Health Commercial |
$305.90
|
| Rate for Payer: Humana Commercial |
$273.70
|
| Rate for Payer: Humana KY Medicaid |
$110.74
|
| Rate for Payer: Humana Medicare Advantage |
$173.12
|
| Rate for Payer: Kentucky WC Medicaid |
$111.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$264.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$237.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$207.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$283.36
|
| Rate for Payer: Ohio Health Group HMO |
$241.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$41.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.82
|
| Rate for Payer: PHCS Commercial |
$309.12
|
| Rate for Payer: United Healthcare All Payer |
$283.36
|
|
|
DES MAL LES 2.1-3CM FEENL
|
Facility
|
OP
|
$958.00
|
|
|
Service Code
|
HCPCS 17283
|
| Hospital Charge Code |
76100269
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$124.54 |
| Max. Negotiated Rate |
$919.68 |
| Rate for Payer: Aetna Commercial |
$737.66
|
| Rate for Payer: Anthem Medicaid |
$329.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$747.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cash Price |
$479.00
|
| Rate for Payer: Cigna Commercial |
$795.14
|
| Rate for Payer: First Health Commercial |
$910.10
|
| Rate for Payer: Humana Commercial |
$814.30
|
| Rate for Payer: Humana KY Medicaid |
$329.46
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$332.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$785.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$707.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$336.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$843.04
|
| Rate for Payer: Ohio Health Group HMO |
$718.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$191.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$296.98
|
| Rate for Payer: PHCS Commercial |
$919.68
|
| Rate for Payer: United Healthcare All Payer |
$843.04
|
|
