|
DIGOXIN
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS 80162
|
| Hospital Charge Code |
30000025
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$13.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.28
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$13.28
|
| Rate for Payer: Humana Medicare Advantage |
$13.28
|
| Rate for Payer: Kentucky WC Medicaid |
$13.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
DILANTIN 100 MG CAP DAW
|
Facility
|
IP
|
$9.86
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
25000567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.47 |
| Rate for Payer: Aetna Commercial |
$7.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.69
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna Commercial |
$8.18
|
| Rate for Payer: First Health Commercial |
$9.37
|
| Rate for Payer: Humana Commercial |
$8.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.68
|
| Rate for Payer: Ohio Health Group HMO |
$7.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$9.47
|
| Rate for Payer: United Healthcare All Payer |
$8.68
|
|
|
DILANTIN 100 MG CAP DAW
|
Facility
|
OP
|
$9.86
|
|
|
Service Code
|
NDC 71036940
|
| Hospital Charge Code |
25000567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$9.47 |
| Rate for Payer: Aetna Commercial |
$7.59
|
| Rate for Payer: Anthem Medicaid |
$3.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.69
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna Commercial |
$8.18
|
| Rate for Payer: First Health Commercial |
$9.37
|
| Rate for Payer: Humana Commercial |
$8.38
|
| Rate for Payer: Humana KY Medicaid |
$3.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.68
|
| Rate for Payer: Ohio Health Group HMO |
$7.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$9.47
|
| Rate for Payer: United Healthcare All Payer |
$8.68
|
|
|
DILANTIN 50 MG (100MG/2ML)
|
Facility
|
OP
|
$77.39
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$59.59
|
| Rate for Payer: Anthem Medicaid |
$26.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.36
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$64.23
|
| Rate for Payer: First Health Commercial |
$73.52
|
| Rate for Payer: Humana Commercial |
$65.78
|
| Rate for Payer: Humana KY Medicaid |
$26.61
|
| Rate for Payer: Kentucky WC Medicaid |
$26.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.10
|
| Rate for Payer: Ohio Health Group HMO |
$58.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.99
|
| Rate for Payer: PHCS Commercial |
$74.29
|
| Rate for Payer: United Healthcare All Payer |
$68.10
|
|
|
DILANTIN 50 MG (100MG/2ML)
|
Facility
|
IP
|
$77.39
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002022
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$74.29 |
| Rate for Payer: Aetna Commercial |
$59.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.36
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$64.23
|
| Rate for Payer: First Health Commercial |
$73.52
|
| Rate for Payer: Humana Commercial |
$65.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.10
|
| Rate for Payer: Ohio Health Group HMO |
$58.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.99
|
| Rate for Payer: PHCS Commercial |
$74.29
|
| Rate for Payer: United Healthcare All Payer |
$68.10
|
|
|
DILANTIN 50MG/ML (250MG/5MLVL)
|
Facility
|
IP
|
$77.99
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$74.87 |
| Rate for Payer: Aetna Commercial |
$60.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.83
|
| Rate for Payer: Cash Price |
$38.99
|
| Rate for Payer: Cigna Commercial |
$64.73
|
| Rate for Payer: First Health Commercial |
$74.09
|
| Rate for Payer: Humana Commercial |
$66.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.63
|
| Rate for Payer: Ohio Health Group HMO |
$58.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: PHCS Commercial |
$74.87
|
| Rate for Payer: United Healthcare All Payer |
$68.63
|
|
|
DILANTIN 50MG/ML (250MG/5MLVL)
|
Facility
|
OP
|
$77.99
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
25002023
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.14 |
| Max. Negotiated Rate |
$74.87 |
| Rate for Payer: Aetna Commercial |
$60.05
|
| Rate for Payer: Anthem Medicaid |
$26.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.83
|
| Rate for Payer: Cash Price |
$38.99
|
| Rate for Payer: Cigna Commercial |
$64.73
|
| Rate for Payer: First Health Commercial |
$74.09
|
| Rate for Payer: Humana Commercial |
$66.29
|
| Rate for Payer: Humana KY Medicaid |
$26.82
|
| Rate for Payer: Kentucky WC Medicaid |
$27.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.63
|
| Rate for Payer: Ohio Health Group HMO |
$58.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.18
|
| Rate for Payer: PHCS Commercial |
$74.87
|
| Rate for Payer: United Healthcare All Payer |
$68.63
|
|
|
DILANTIN (PHENYTOIN) 100MG/4ML
|
Facility
|
OP
|
$9.27
|
|
|
Service Code
|
NDC 66689077508
|
| Hospital Charge Code |
25000564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Anthem Medicaid |
$3.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.81
|
| Rate for Payer: Humana Commercial |
$7.88
|
| Rate for Payer: Humana KY Medicaid |
$3.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.16
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Payer |
$8.16
|
|
|
DILANTIN (PHENYTOIN) 100MG/4ML
|
Facility
|
IP
|
$9.27
|
|
|
Service Code
|
NDC 66689077508
|
| Hospital Charge Code |
25000564
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna Commercial |
$7.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.23
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cigna Commercial |
$7.69
|
| Rate for Payer: First Health Commercial |
$8.81
|
| Rate for Payer: Humana Commercial |
$7.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.16
|
| Rate for Payer: Ohio Health Group HMO |
$6.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$8.90
|
| Rate for Payer: United Healthcare All Payer |
$8.16
|
|
|
DILANTIN (PHENYTOIN) 30MG/1CAP
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 71374066
|
| Hospital Charge Code |
25000565
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.98
|
| Rate for Payer: Humana Commercial |
$8.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.32
|
| Rate for Payer: Ohio Health Group HMO |
$7.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$9.07
|
| Rate for Payer: United Healthcare All Payer |
$8.32
|
|
|
DILANTIN (PHENYTOIN) 30MG/1CAP
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 71374066
|
| Hospital Charge Code |
25000565
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.07 |
| Rate for Payer: Aetna Commercial |
$7.28
|
| Rate for Payer: Anthem Medicaid |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.37
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.98
|
| Rate for Payer: Humana Commercial |
$8.03
|
| Rate for Payer: Humana KY Medicaid |
$3.25
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.32
|
| Rate for Payer: Ohio Health Group HMO |
$7.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$9.07
|
| Rate for Payer: United Healthcare All Payer |
$8.32
|
|
|
DILANTIN (PHENYTOIN) 50MG/1TAB
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 51672414601
|
| Hospital Charge Code |
25000566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
DILANTIN (PHENYTOIN) 50MG/1TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 51672414601
|
| Hospital Charge Code |
25000566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
|
|
DILANTIN TOTAL
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
30000043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$13.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.25
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$13.25
|
| Rate for Payer: Humana Medicare Advantage |
$13.25
|
| Rate for Payer: Kentucky WC Medicaid |
$13.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.13
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
DILANTIN TOTAL
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
30000043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.99 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.13
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
DILATE ESOPHAGUS 1/MULT PAS(P
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
761P1776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.95 |
| Max. Negotiated Rate |
$415.00 |
| Rate for Payer: Aetna Commercial |
$134.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.41
|
| Rate for Payer: Anthem Medicaid |
$59.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$415.00
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$120.81
|
| Rate for Payer: Healthspan PPO |
$192.05
|
| Rate for Payer: Humana Medicaid |
$59.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.15
|
| Rate for Payer: Molina Healthcare Passport |
$59.95
|
| Rate for Payer: Multiplan PHCS |
$249.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$290.50
|
| Rate for Payer: UHCCP Medicaid |
$79.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.55
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Facility
|
IP
|
$2,363.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
76101776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$307.23 |
| Max. Negotiated Rate |
$2,268.79 |
| Rate for Payer: Aetna Commercial |
$1,819.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,843.39
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cigna Commercial |
$1,961.56
|
| Rate for Payer: First Health Commercial |
$2,245.15
|
| Rate for Payer: Humana Commercial |
$2,008.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,937.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,744.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$709.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,079.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,772.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$472.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$732.63
|
| Rate for Payer: PHCS Commercial |
$2,268.79
|
| Rate for Payer: United Healthcare All Payer |
$2,079.72
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Professional
|
Both
|
$2,363.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
76101776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.95 |
| Max. Negotiated Rate |
$2,363.32 |
| Rate for Payer: Aetna Commercial |
$134.60
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.41
|
| Rate for Payer: Anthem Medicaid |
$59.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,363.32
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cigna Commercial |
$120.81
|
| Rate for Payer: Healthspan PPO |
$192.05
|
| Rate for Payer: Humana Medicaid |
$59.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.15
|
| Rate for Payer: Molina Healthcare Passport |
$59.95
|
| Rate for Payer: Multiplan PHCS |
$1,417.99
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,654.32
|
| Rate for Payer: UHCCP Medicaid |
$79.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.55
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Facility
|
OP
|
$2,363.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
76101776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$307.23 |
| Max. Negotiated Rate |
$2,268.79 |
| Rate for Payer: Aetna Commercial |
$1,819.76
|
| Rate for Payer: Anthem Medicaid |
$812.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,843.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cigna Commercial |
$1,961.56
|
| Rate for Payer: First Health Commercial |
$2,245.15
|
| Rate for Payer: Humana Commercial |
$2,008.82
|
| Rate for Payer: Humana KY Medicaid |
$812.75
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$821.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,937.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,744.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$829.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,079.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,772.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$472.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$307.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$732.63
|
| Rate for Payer: PHCS Commercial |
$2,268.79
|
| Rate for Payer: United Healthcare All Payer |
$2,079.72
|
|
|
DILATE ESOPHAGUS 1/MULT PAS(T
|
Facility
|
OP
|
$1,948.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
761T1776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.28 |
| Max. Negotiated Rate |
$1,870.39 |
| Rate for Payer: Aetna Commercial |
$1,500.21
|
| Rate for Payer: Anthem Medicaid |
$670.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$783.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,097.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,058.25
|
| Rate for Payer: Cash Price |
$974.16
|
| Rate for Payer: Cash Price |
$974.16
|
| Rate for Payer: Cigna Commercial |
$1,617.11
|
| Rate for Payer: First Health Commercial |
$1,850.90
|
| Rate for Payer: Humana Commercial |
$1,656.07
|
| Rate for Payer: Humana KY Medicaid |
$670.03
|
| Rate for Payer: Humana Medicare Advantage |
$783.89
|
| Rate for Payer: Kentucky WC Medicaid |
$676.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$940.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$683.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.98
|
| Rate for Payer: PHCS Commercial |
$1,870.39
|
| Rate for Payer: United Healthcare All Payer |
$1,714.52
|
|
|
DILATE ESOPHAGUS 1/MULT PAS(T
|
Facility
|
IP
|
$1,948.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
761T1776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$253.28 |
| Max. Negotiated Rate |
$1,870.39 |
| Rate for Payer: Aetna Commercial |
$1,500.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.69
|
| Rate for Payer: Cash Price |
$974.16
|
| Rate for Payer: Cigna Commercial |
$1,617.11
|
| Rate for Payer: First Health Commercial |
$1,850.90
|
| Rate for Payer: Humana Commercial |
$1,656.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.98
|
| Rate for Payer: PHCS Commercial |
$1,870.39
|
| Rate for Payer: United Healthcare All Payer |
$1,714.52
|
|
|
DILATE URETHRA STRICTURE
|
Professional
|
Both
|
$290.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
76102782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.93 |
| Max. Negotiated Rate |
$290.00 |
| Rate for Payer: Aetna Commercial |
$88.86
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.93
|
| Rate for Payer: Anthem Medicaid |
$33.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$127.60
|
| Rate for Payer: Healthspan PPO |
$107.00
|
| Rate for Payer: Humana Medicaid |
$33.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.04
|
| Rate for Payer: Molina Healthcare Passport |
$33.37
|
| Rate for Payer: Multiplan PHCS |
$174.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$203.00
|
| Rate for Payer: UHCCP Medicaid |
$33.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.70
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
OP
|
$290.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
76102782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.70 |
| Max. Negotiated Rate |
$278.40 |
| Rate for Payer: Aetna Commercial |
$223.30
|
| Rate for Payer: Anthem Medicaid |
$99.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$240.70
|
| Rate for Payer: First Health Commercial |
$275.50
|
| Rate for Payer: Humana Commercial |
$246.50
|
| Rate for Payer: Humana KY Medicaid |
$99.73
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$100.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$237.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$101.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$255.20
|
| Rate for Payer: Ohio Health Group HMO |
$217.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.90
|
| Rate for Payer: PHCS Commercial |
$278.40
|
| Rate for Payer: United Healthcare All Payer |
$255.20
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
IP
|
$290.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
76102782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.70 |
| Max. Negotiated Rate |
$278.40 |
| Rate for Payer: Aetna Commercial |
$223.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$226.20
|
| Rate for Payer: Cash Price |
$145.00
|
| Rate for Payer: Cigna Commercial |
$240.70
|
| Rate for Payer: First Health Commercial |
$275.50
|
| Rate for Payer: Humana Commercial |
$246.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$237.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$214.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$255.20
|
| Rate for Payer: Ohio Health Group HMO |
$217.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.90
|
| Rate for Payer: PHCS Commercial |
$278.40
|
| Rate for Payer: United Healthcare All Payer |
$255.20
|
|
|
DILATE URETHRA STRICTURE (P
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
761P2782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.93 |
| Max. Negotiated Rate |
$127.60 |
| Rate for Payer: Aetna Commercial |
$88.86
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.93
|
| Rate for Payer: Anthem Medicaid |
$33.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$110.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$127.60
|
| Rate for Payer: Healthspan PPO |
$107.00
|
| Rate for Payer: Humana Medicaid |
$33.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$34.04
|
| Rate for Payer: Molina Healthcare Passport |
$33.37
|
| Rate for Payer: Multiplan PHCS |
$66.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$77.00
|
| Rate for Payer: UHCCP Medicaid |
$33.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$33.70
|
|
