|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$664.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
761T2117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.32 |
| Max. Negotiated Rate |
$637.44 |
| Rate for Payer: Aetna Commercial |
$511.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$517.92
|
| Rate for Payer: Cash Price |
$332.00
|
| Rate for Payer: Cigna Commercial |
$551.12
|
| Rate for Payer: First Health Commercial |
$630.80
|
| Rate for Payer: Humana Commercial |
$564.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$544.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$490.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$199.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$584.32
|
| Rate for Payer: Ohio Health Group HMO |
$498.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$205.84
|
| Rate for Payer: PHCS Commercial |
$637.44
|
| Rate for Payer: United Healthcare All Payer |
$584.32
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$620.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
76102120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$620.00 |
| Rate for Payer: Aetna Commercial |
$67.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.20
|
| Rate for Payer: Anthem Medicaid |
$25.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$620.00
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$112.85
|
| Rate for Payer: Healthspan PPO |
$92.11
|
| Rate for Payer: Humana Medicaid |
$25.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$56.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.83
|
| Rate for Payer: Molina Healthcare Passport |
$25.32
|
| Rate for Payer: Multiplan PHCS |
$372.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$434.00
|
| Rate for Payer: UHCCP Medicaid |
$26.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.57
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$664.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
761T2117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.32 |
| Max. Negotiated Rate |
$637.44 |
| Rate for Payer: Aetna Commercial |
$511.28
|
| Rate for Payer: Anthem Medicaid |
$228.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$517.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$332.00
|
| Rate for Payer: Cash Price |
$332.00
|
| Rate for Payer: Cigna Commercial |
$551.12
|
| Rate for Payer: First Health Commercial |
$630.80
|
| Rate for Payer: Humana Commercial |
$564.40
|
| Rate for Payer: Humana KY Medicaid |
$228.35
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$230.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$544.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$490.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$232.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$584.32
|
| Rate for Payer: Ohio Health Group HMO |
$498.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$205.84
|
| Rate for Payer: PHCS Commercial |
$637.44
|
| Rate for Payer: United Healthcare All Payer |
$584.32
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
761P2120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$67.57
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$25.20
|
| Rate for Payer: Anthem Medicaid |
$25.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$375.00
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$112.85
|
| Rate for Payer: Healthspan PPO |
$92.11
|
| Rate for Payer: Humana Medicaid |
$25.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$56.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.83
|
| Rate for Payer: Molina Healthcare Passport |
$25.32
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.50
|
| Rate for Payer: UHCCP Medicaid |
$26.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.57
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$245.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
761T2120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.95
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
IP
|
$620.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
76102120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.60 |
| Max. Negotiated Rate |
$595.20 |
| Rate for Payer: Aetna Commercial |
$477.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.60
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$514.60
|
| Rate for Payer: First Health Commercial |
$589.00
|
| Rate for Payer: Humana Commercial |
$527.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$186.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.60
|
| Rate for Payer: Ohio Health Group HMO |
$465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.20
|
| Rate for Payer: PHCS Commercial |
$595.20
|
| Rate for Payer: United Healthcare All Payer |
$545.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$929.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
76102117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.77 |
| Max. Negotiated Rate |
$891.84 |
| Rate for Payer: Aetna Commercial |
$715.33
|
| Rate for Payer: Anthem Medicaid |
$319.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$724.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$464.50
|
| Rate for Payer: Cash Price |
$464.50
|
| Rate for Payer: Cigna Commercial |
$771.07
|
| Rate for Payer: First Health Commercial |
$882.55
|
| Rate for Payer: Humana Commercial |
$789.65
|
| Rate for Payer: Humana KY Medicaid |
$319.48
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$322.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$761.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$685.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$325.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$817.52
|
| Rate for Payer: Ohio Health Group HMO |
$696.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$185.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$120.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$287.99
|
| Rate for Payer: PHCS Commercial |
$891.84
|
| Rate for Payer: United Healthcare All Payer |
$817.52
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$620.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
76102120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$80.60 |
| Max. Negotiated Rate |
$595.20 |
| Rate for Payer: Aetna Commercial |
$477.40
|
| Rate for Payer: Anthem Medicaid |
$213.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$483.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cash Price |
$310.00
|
| Rate for Payer: Cigna Commercial |
$514.60
|
| Rate for Payer: First Health Commercial |
$589.00
|
| Rate for Payer: Humana Commercial |
$527.00
|
| Rate for Payer: Humana KY Medicaid |
$213.22
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$215.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$508.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$457.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$217.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$545.60
|
| Rate for Payer: Ohio Health Group HMO |
$465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$192.20
|
| Rate for Payer: PHCS Commercial |
$595.20
|
| Rate for Payer: United Healthcare All Payer |
$545.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Facility
|
OP
|
$245.00
|
|
|
Service Code
|
HCPCS 53660
|
| Hospital Charge Code |
761T2120
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.85 |
| Max. Negotiated Rate |
$235.20 |
| Rate for Payer: Aetna Commercial |
$188.65
|
| Rate for Payer: Anthem Medicaid |
$84.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$191.10
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$203.35
|
| Rate for Payer: First Health Commercial |
$232.75
|
| Rate for Payer: Humana Commercial |
$208.25
|
| Rate for Payer: Humana KY Medicaid |
$84.26
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$85.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$215.60
|
| Rate for Payer: Ohio Health Group HMO |
$183.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$49.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$31.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$75.95
|
| Rate for Payer: PHCS Commercial |
$235.20
|
| Rate for Payer: United Healthcare All Payer |
$215.60
|
|
|
DILAT URETH STRIX DIL MALE 1ST
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
HCPCS 53600
|
| Hospital Charge Code |
761P2117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$40.66 |
| Max. Negotiated Rate |
$265.00 |
| Rate for Payer: Aetna Commercial |
$106.77
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$40.94
|
| Rate for Payer: Anthem Medicaid |
$40.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$265.00
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cigna Commercial |
$132.86
|
| Rate for Payer: Healthspan PPO |
$111.05
|
| Rate for Payer: Humana Medicaid |
$40.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$86.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.47
|
| Rate for Payer: Molina Healthcare Passport |
$40.66
|
| Rate for Payer: Multiplan PHCS |
$159.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$185.50
|
| Rate for Payer: UHCCP Medicaid |
$42.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$41.07
|
|
|
DILAUDID [0.1MG] 1MG/1ML VIAL
|
Facility
|
OP
|
$77.60
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.09 |
| Max. Negotiated Rate |
$74.50 |
| Rate for Payer: Aetna Commercial |
$59.75
|
| Rate for Payer: Anthem Medicaid |
$26.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.53
|
| Rate for Payer: Cash Price |
$38.80
|
| Rate for Payer: Cigna Commercial |
$64.41
|
| Rate for Payer: First Health Commercial |
$73.72
|
| Rate for Payer: Humana Commercial |
$65.96
|
| Rate for Payer: Humana KY Medicaid |
$26.69
|
| Rate for Payer: Kentucky WC Medicaid |
$26.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.29
|
| Rate for Payer: Ohio Health Group HMO |
$58.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.06
|
| Rate for Payer: PHCS Commercial |
$74.50
|
| Rate for Payer: United Healthcare All Payer |
$68.29
|
|
|
DILAUDID [0.1MG] 1MG/1ML VIAL
|
Facility
|
IP
|
$77.60
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.09 |
| Max. Negotiated Rate |
$74.50 |
| Rate for Payer: Aetna Commercial |
$59.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.53
|
| Rate for Payer: Cash Price |
$38.80
|
| Rate for Payer: Cigna Commercial |
$64.41
|
| Rate for Payer: First Health Commercial |
$73.72
|
| Rate for Payer: Humana Commercial |
$65.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.29
|
| Rate for Payer: Ohio Health Group HMO |
$58.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.06
|
| Rate for Payer: PHCS Commercial |
$74.50
|
| Rate for Payer: United Healthcare All Payer |
$68.29
|
|
|
DILAUDID [0.1MG] 2MG/1ML VIAL
|
Facility
|
IP
|
$78.37
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.13
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.05
|
| Rate for Payer: First Health Commercial |
$74.45
|
| Rate for Payer: Humana Commercial |
$66.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.29
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
DILAUDID [0.1MG] 2MG/1ML VIAL
|
Facility
|
OP
|
$78.37
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.19 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Anthem Medicaid |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.13
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.05
|
| Rate for Payer: First Health Commercial |
$74.45
|
| Rate for Payer: Humana Commercial |
$66.61
|
| Rate for Payer: Humana KY Medicaid |
$26.95
|
| Rate for Payer: Kentucky WC Medicaid |
$27.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.29
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
| Rate for Payer: Aetna Commercial |
$60.34
|
|
|
DILAUDID 0.1MG 40MG/20ML VIAL
|
Facility
|
OP
|
$128.43
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$123.29 |
| Rate for Payer: Aetna Commercial |
$98.89
|
| Rate for Payer: Anthem Medicaid |
$44.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.18
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cigna Commercial |
$106.60
|
| Rate for Payer: First Health Commercial |
$122.01
|
| Rate for Payer: Humana Commercial |
$109.17
|
| Rate for Payer: Humana KY Medicaid |
$44.17
|
| Rate for Payer: Kentucky WC Medicaid |
$44.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.02
|
| Rate for Payer: Ohio Health Group HMO |
$96.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.81
|
| Rate for Payer: PHCS Commercial |
$123.29
|
| Rate for Payer: United Healthcare All Payer |
$113.02
|
|
|
DILAUDID 0.1MG 40MG/20ML VIAL
|
Facility
|
IP
|
$128.43
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.70 |
| Max. Negotiated Rate |
$123.29 |
| Rate for Payer: Aetna Commercial |
$98.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.18
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cigna Commercial |
$106.60
|
| Rate for Payer: First Health Commercial |
$122.01
|
| Rate for Payer: Humana Commercial |
$109.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.02
|
| Rate for Payer: Ohio Health Group HMO |
$96.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.81
|
| Rate for Payer: PHCS Commercial |
$123.29
|
| Rate for Payer: United Healthcare All Payer |
$113.02
|
|
|
DILAUDID 0.1MG 4MG/1ML TUBEX
|
Facility
|
OP
|
$78.15
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.02 |
| Rate for Payer: Aetna Commercial |
$60.18
|
| Rate for Payer: Anthem Medicaid |
$26.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.96
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.86
|
| Rate for Payer: First Health Commercial |
$74.24
|
| Rate for Payer: Humana Commercial |
$66.43
|
| Rate for Payer: Humana KY Medicaid |
$26.88
|
| Rate for Payer: Kentucky WC Medicaid |
$27.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.77
|
| Rate for Payer: Ohio Health Group HMO |
$58.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.23
|
| Rate for Payer: PHCS Commercial |
$75.02
|
| Rate for Payer: United Healthcare All Payer |
$68.77
|
|
|
DILAUDID 0.1MG 4MG/1ML TUBEX
|
Facility
|
IP
|
$78.15
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$75.02 |
| Rate for Payer: Aetna Commercial |
$60.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.96
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.86
|
| Rate for Payer: First Health Commercial |
$74.24
|
| Rate for Payer: Humana Commercial |
$66.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.77
|
| Rate for Payer: Ohio Health Group HMO |
$58.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.23
|
| Rate for Payer: PHCS Commercial |
$75.02
|
| Rate for Payer: United Healthcare All Payer |
$68.77
|
|
|
DILAUDID 0.1 MG(500MG/50ML VL)
|
Facility
|
IP
|
$178.50
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$171.36 |
| Rate for Payer: Aetna Commercial |
$137.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.23
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Cigna Commercial |
$148.16
|
| Rate for Payer: First Health Commercial |
$169.58
|
| Rate for Payer: Humana Commercial |
$151.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.08
|
| Rate for Payer: Ohio Health Group HMO |
$133.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.34
|
| Rate for Payer: PHCS Commercial |
$171.36
|
| Rate for Payer: United Healthcare All Payer |
$157.08
|
|
|
DILAUDID 0.1 MG(500MG/50ML VL)
|
Facility
|
OP
|
$178.50
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$171.36 |
| Rate for Payer: Aetna Commercial |
$137.44
|
| Rate for Payer: Anthem Medicaid |
$61.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.23
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Cigna Commercial |
$148.16
|
| Rate for Payer: First Health Commercial |
$169.58
|
| Rate for Payer: Humana Commercial |
$151.72
|
| Rate for Payer: Humana KY Medicaid |
$61.39
|
| Rate for Payer: Kentucky WC Medicaid |
$62.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.08
|
| Rate for Payer: Ohio Health Group HMO |
$133.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.34
|
| Rate for Payer: PHCS Commercial |
$171.36
|
| Rate for Payer: United Healthcare All Payer |
$157.08
|
|
|
DILAUDID(HYDROM)SUPPO 3MG/1EA
|
Facility
|
OP
|
$69.81
|
|
|
Service Code
|
NDC 574722406
|
| Hospital Charge Code |
25002777
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$67.02 |
| Rate for Payer: Aetna Commercial |
$53.75
|
| Rate for Payer: Anthem Medicaid |
$24.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.45
|
| Rate for Payer: Cash Price |
$34.91
|
| Rate for Payer: Cigna Commercial |
$57.94
|
| Rate for Payer: First Health Commercial |
$66.32
|
| Rate for Payer: Humana Commercial |
$59.34
|
| Rate for Payer: Humana KY Medicaid |
$24.01
|
| Rate for Payer: Kentucky WC Medicaid |
$24.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.43
|
| Rate for Payer: Ohio Health Group HMO |
$52.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.64
|
| Rate for Payer: PHCS Commercial |
$67.02
|
| Rate for Payer: United Healthcare All Payer |
$61.43
|
|
|
DILAUDID(HYDROM)SUPPO 3MG/1EA
|
Facility
|
IP
|
$69.81
|
|
|
Service Code
|
NDC 574722406
|
| Hospital Charge Code |
25002777
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.08 |
| Max. Negotiated Rate |
$67.02 |
| Rate for Payer: Aetna Commercial |
$53.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.45
|
| Rate for Payer: Cash Price |
$34.91
|
| Rate for Payer: Cigna Commercial |
$57.94
|
| Rate for Payer: First Health Commercial |
$66.32
|
| Rate for Payer: Humana Commercial |
$59.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.43
|
| Rate for Payer: Ohio Health Group HMO |
$52.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.64
|
| Rate for Payer: PHCS Commercial |
$67.02
|
| Rate for Payer: United Healthcare All Payer |
$61.43
|
|
|
DIL FEM URT WSUPP/INSTLJ SBS(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
761P2121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$66.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.42
|
| Rate for Payer: Anthem Medicaid |
$25.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$375.00
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Healthspan PPO |
$91.71
|
| Rate for Payer: Humana Medicaid |
$25.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.71
|
| Rate for Payer: Molina Healthcare Passport |
$25.21
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.50
|
| Rate for Payer: UHCCP Medicaid |
$25.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.46
|
|
|
DIL FEM URT WSUPP/INSTLJ SBSQ
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
76102121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$69.03 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$164.61
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
DIL FEM URT WSUPP/INSTLJ SBSQ
|
Professional
|
Both
|
$531.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
76102121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$531.00 |
| Rate for Payer: Aetna Commercial |
$66.53
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.42
|
| Rate for Payer: Anthem Medicaid |
$25.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$531.00
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Healthspan PPO |
$91.71
|
| Rate for Payer: Humana Medicaid |
$25.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$25.71
|
| Rate for Payer: Molina Healthcare Passport |
$25.21
|
| Rate for Payer: Multiplan PHCS |
$318.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$371.70
|
| Rate for Payer: UHCCP Medicaid |
$25.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$25.46
|
|
