|
DOTAREM 0.5MMOL/ML 20ML VIAL
|
Facility
|
IP
|
$177.60
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25003030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.09 |
| Max. Negotiated Rate |
$170.50 |
| Rate for Payer: Aetna Commercial |
$136.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$138.53
|
| Rate for Payer: Cash Price |
$88.80
|
| Rate for Payer: Cigna Commercial |
$147.41
|
| Rate for Payer: First Health Commercial |
$168.72
|
| Rate for Payer: Humana Commercial |
$150.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$145.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$156.29
|
| Rate for Payer: Ohio Health Group HMO |
$133.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.06
|
| Rate for Payer: PHCS Commercial |
$170.50
|
| Rate for Payer: United Healthcare All Payer |
$156.29
|
|
|
DOTAREM 0.5MOL/ML 5ML VIAL
|
Facility
|
IP
|
$34.77
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$33.38 |
| Rate for Payer: Aetna Commercial |
$26.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.12
|
| Rate for Payer: Cash Price |
$17.39
|
| Rate for Payer: Cigna Commercial |
$28.86
|
| Rate for Payer: First Health Commercial |
$33.03
|
| Rate for Payer: Humana Commercial |
$29.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.60
|
| Rate for Payer: Ohio Health Group HMO |
$26.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.78
|
| Rate for Payer: PHCS Commercial |
$33.38
|
| Rate for Payer: United Healthcare All Payer |
$30.60
|
|
|
DOTAREM 0.5MOL/ML 5ML VIAL
|
Facility
|
OP
|
$34.77
|
|
|
Service Code
|
HCPCS A9575
|
| Hospital Charge Code |
25001802
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$33.38 |
| Rate for Payer: Aetna Commercial |
$26.77
|
| Rate for Payer: Anthem Medicaid |
$11.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.12
|
| Rate for Payer: Cash Price |
$17.39
|
| Rate for Payer: Cigna Commercial |
$28.86
|
| Rate for Payer: First Health Commercial |
$33.03
|
| Rate for Payer: Humana Commercial |
$29.55
|
| Rate for Payer: Humana KY Medicaid |
$11.96
|
| Rate for Payer: Kentucky WC Medicaid |
$12.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.60
|
| Rate for Payer: Ohio Health Group HMO |
$26.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.78
|
| Rate for Payer: PHCS Commercial |
$33.38
|
| Rate for Payer: United Healthcare All Payer |
$30.60
|
|
|
DOVONEX 0.005% CREAM(60GM)
|
Facility
|
OP
|
$10.64
|
|
|
Service Code
|
NDC 68462050165
|
| Hospital Charge Code |
25003031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$10.21 |
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: Anthem Medicaid |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.30
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Cigna Commercial |
$8.83
|
| Rate for Payer: First Health Commercial |
$10.11
|
| Rate for Payer: Humana Commercial |
$9.04
|
| Rate for Payer: Humana KY Medicaid |
$3.66
|
| Rate for Payer: Kentucky WC Medicaid |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$10.21
|
| Rate for Payer: United Healthcare All Payer |
$9.36
|
|
|
DOVONEX 0.005% CREAM(60GM)
|
Facility
|
IP
|
$10.64
|
|
|
Service Code
|
NDC 68462050165
|
| Hospital Charge Code |
25003031
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$10.21 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.36
|
| Rate for Payer: Ohio Health Group HMO |
$7.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$10.21
|
| Rate for Payer: United Healthcare All Payer |
$9.36
|
| Rate for Payer: Aetna Commercial |
$8.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.30
|
| Rate for Payer: Cash Price |
$5.32
|
| Rate for Payer: Cigna Commercial |
$8.83
|
| Rate for Payer: First Health Commercial |
$10.11
|
| Rate for Payer: Humana Commercial |
$9.04
|
|
|
DOXEPIN 10NG/ML ORAL CON (1ML)
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 54838051240
|
| Hospital Charge Code |
25000580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
DOXEPIN 10NG/ML ORAL CON (1ML)
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 54838051240
|
| Hospital Charge Code |
25000580
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
DOXIL 10MG 20MG/10ML VL
|
Facility
|
IP
|
$1,744.87
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25002718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$226.83 |
| Max. Negotiated Rate |
$1,675.08 |
| Rate for Payer: Aetna Commercial |
$1,343.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,361.00
|
| Rate for Payer: Cash Price |
$872.43
|
| Rate for Payer: Cigna Commercial |
$1,448.24
|
| Rate for Payer: First Health Commercial |
$1,657.63
|
| Rate for Payer: Humana Commercial |
$1,483.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,430.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,287.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$523.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,535.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,308.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$540.91
|
| Rate for Payer: PHCS Commercial |
$1,675.08
|
| Rate for Payer: United Healthcare All Payer |
$1,535.49
|
|
|
DOXIL 10MG 20MG/10ML VL
|
Facility
|
OP
|
$1,744.87
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25002718
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.48 |
| Max. Negotiated Rate |
$1,675.08 |
| Rate for Payer: Aetna Commercial |
$1,343.55
|
| Rate for Payer: Anthem Medicaid |
$600.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,361.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$115.40
|
| Rate for Payer: Cash Price |
$872.43
|
| Rate for Payer: Cash Price |
$872.43
|
| Rate for Payer: Cigna Commercial |
$1,448.24
|
| Rate for Payer: First Health Commercial |
$1,657.63
|
| Rate for Payer: Humana Commercial |
$1,483.14
|
| Rate for Payer: Humana KY Medicaid |
$600.06
|
| Rate for Payer: Humana Medicare Advantage |
$85.48
|
| Rate for Payer: Kentucky WC Medicaid |
$606.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,430.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,287.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$612.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,535.49
|
| Rate for Payer: Ohio Health Group HMO |
$1,308.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$348.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$540.91
|
| Rate for Payer: PHCS Commercial |
$1,675.08
|
| Rate for Payer: United Healthcare All Payer |
$1,535.49
|
|
|
DOXIL 10MG 50MG/25ML VL
|
Facility
|
OP
|
$9,177.80
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25003777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$85.48 |
| Max. Negotiated Rate |
$8,810.69 |
| Rate for Payer: Aetna Commercial |
$7,066.91
|
| Rate for Payer: Anthem Medicaid |
$3,156.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$85.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,158.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$119.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$115.40
|
| Rate for Payer: Cash Price |
$4,588.90
|
| Rate for Payer: Cash Price |
$4,588.90
|
| Rate for Payer: Cigna Commercial |
$7,617.57
|
| Rate for Payer: First Health Commercial |
$8,718.91
|
| Rate for Payer: Humana Commercial |
$7,801.13
|
| Rate for Payer: Humana KY Medicaid |
$3,156.25
|
| Rate for Payer: Humana Medicare Advantage |
$85.48
|
| Rate for Payer: Kentucky WC Medicaid |
$3,188.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,525.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,773.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,219.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,076.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,883.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,835.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,193.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,845.12
|
| Rate for Payer: PHCS Commercial |
$8,810.69
|
| Rate for Payer: United Healthcare All Payer |
$8,076.46
|
|
|
DOXIL 10MG 50MG/25ML VL
|
Facility
|
IP
|
$9,177.80
|
|
|
Service Code
|
HCPCS Q2050
|
| Hospital Charge Code |
25003777
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,193.11 |
| Max. Negotiated Rate |
$8,810.69 |
| Rate for Payer: Aetna Commercial |
$7,066.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,158.68
|
| Rate for Payer: Cash Price |
$4,588.90
|
| Rate for Payer: Cigna Commercial |
$7,617.57
|
| Rate for Payer: First Health Commercial |
$8,718.91
|
| Rate for Payer: Humana Commercial |
$7,801.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,525.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,773.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,753.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,076.46
|
| Rate for Payer: Ohio Health Group HMO |
$6,883.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,835.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,193.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,845.12
|
| Rate for Payer: PHCS Commercial |
$8,810.69
|
| Rate for Payer: United Healthcare All Payer |
$8,076.46
|
|
|
DOXYCYCLINE 100mg BAG (ANES)
|
Facility
|
IP
|
$131.16
|
|
|
Service Code
|
NDC 68382091001
|
| Hospital Charge Code |
25004156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$125.91 |
| Rate for Payer: Aetna Commercial |
$100.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.30
|
| Rate for Payer: Cash Price |
$65.58
|
| Rate for Payer: Cigna Commercial |
$108.86
|
| Rate for Payer: First Health Commercial |
$124.60
|
| Rate for Payer: Humana Commercial |
$111.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.42
|
| Rate for Payer: Ohio Health Group HMO |
$98.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.66
|
| Rate for Payer: PHCS Commercial |
$125.91
|
| Rate for Payer: United Healthcare All Payer |
$115.42
|
|
|
DOXYCYCLINE 100mg BAG (ANES)
|
Facility
|
OP
|
$131.16
|
|
|
Service Code
|
NDC 68382091001
|
| Hospital Charge Code |
25004156
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.05 |
| Max. Negotiated Rate |
$125.91 |
| Rate for Payer: Humana Commercial |
$111.49
|
| Rate for Payer: Humana KY Medicaid |
$45.11
|
| Rate for Payer: Kentucky WC Medicaid |
$45.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.42
|
| Rate for Payer: Ohio Health Group HMO |
$98.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$40.66
|
| Rate for Payer: PHCS Commercial |
$125.91
|
| Rate for Payer: United Healthcare All Payer |
$115.42
|
| Rate for Payer: Aetna Commercial |
$100.99
|
| Rate for Payer: Anthem Medicaid |
$45.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.30
|
| Rate for Payer: Cash Price |
$65.58
|
| Rate for Payer: Cigna Commercial |
$108.86
|
| Rate for Payer: First Health Commercial |
$124.60
|
|
|
DOXY+NYST+HC Mouthwash 120mL
|
Facility
|
IP
|
$53.96
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
25004124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$41.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.09
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cigna Commercial |
$44.79
|
| Rate for Payer: First Health Commercial |
$51.26
|
| Rate for Payer: Humana Commercial |
$45.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.48
|
| Rate for Payer: Ohio Health Group HMO |
$40.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$51.80
|
| Rate for Payer: United Healthcare All Payer |
$47.48
|
|
|
DOXY+NYST+HC Mouthwash 120mL
|
Facility
|
OP
|
$53.96
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
25004124
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.01 |
| Max. Negotiated Rate |
$51.80 |
| Rate for Payer: Aetna Commercial |
$41.55
|
| Rate for Payer: Anthem Medicaid |
$18.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.09
|
| Rate for Payer: Cash Price |
$26.98
|
| Rate for Payer: Cigna Commercial |
$44.79
|
| Rate for Payer: First Health Commercial |
$51.26
|
| Rate for Payer: Humana Commercial |
$45.87
|
| Rate for Payer: Humana KY Medicaid |
$18.56
|
| Rate for Payer: Kentucky WC Medicaid |
$18.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$39.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.48
|
| Rate for Payer: Ohio Health Group HMO |
$40.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.79
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.73
|
| Rate for Payer: PHCS Commercial |
$51.80
|
| Rate for Payer: United Healthcare All Payer |
$47.48
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
76101118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
761P1118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$167.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.46
|
| Rate for Payer: Anthem Medicaid |
$50.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$279.24
|
| Rate for Payer: Healthspan PPO |
$252.02
|
| Rate for Payer: Humana Medicaid |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$151.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$51.00
|
| Rate for Payer: Molina Healthcare Passport |
$50.00
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$68.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$50.50
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
76101118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.00 |
| Max. Negotiated Rate |
$666.11 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem Medicaid |
$171.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Humana KY Medicaid |
$171.95
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$173.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$175.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
45000206
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$666.11 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem Medicaid |
$226.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Humana KY Medicaid |
$226.97
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$229.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$231.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
76101118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$50.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna Commercial |
$167.19
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.46
|
| Rate for Payer: Anthem Medicaid |
$50.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$279.24
|
| Rate for Payer: Healthspan PPO |
$252.02
|
| Rate for Payer: Humana Medicaid |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$151.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$51.00
|
| Rate for Payer: Molina Healthcare Passport |
$50.00
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$68.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$50.50
|
|
|
DRA ABSCES HEMATOMA NASALSEPTU
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS 30020
|
| Hospital Charge Code |
45000206
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$85.80 |
| Max. Negotiated Rate |
$633.60 |
| Rate for Payer: Aetna Commercial |
$508.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$514.80
|
| Rate for Payer: Cash Price |
$330.00
|
| Rate for Payer: Cigna Commercial |
$547.80
|
| Rate for Payer: First Health Commercial |
$627.00
|
| Rate for Payer: Humana Commercial |
$561.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$541.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$487.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$580.80
|
| Rate for Payer: Ohio Health Group HMO |
$495.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$204.60
|
| Rate for Payer: PHCS Commercial |
$633.60
|
| Rate for Payer: United Healthcare All Payer |
$580.80
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLA(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
761P1665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.82 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.56
|
| Rate for Payer: Anthem Medicaid |
$43.82
|
| 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 |
$157.30
|
| Rate for Payer: Healthspan PPO |
$255.68
|
| Rate for Payer: Humana Medicaid |
$43.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.70
|
| Rate for Payer: Molina Healthcare Passport |
$43.82
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$82.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.26
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Professional
|
Both
|
$857.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
76101665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.82 |
| Max. Negotiated Rate |
$857.00 |
| Rate for Payer: Aetna Commercial |
$179.55
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$78.56
|
| Rate for Payer: Anthem Medicaid |
$43.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$857.00
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cigna Commercial |
$157.30
|
| Rate for Payer: Healthspan PPO |
$255.68
|
| Rate for Payer: Humana Medicaid |
$43.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$173.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$44.70
|
| Rate for Payer: Molina Healthcare Passport |
$43.82
|
| Rate for Payer: Multiplan PHCS |
$514.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$599.90
|
| Rate for Payer: UHCCP Medicaid |
$82.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$44.26
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
45000255
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem Medicaid |
$63.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Humana KY Medicaid |
$63.97
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$64.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
DRAIN ABSCESCYSTDENTOALVEOLAR
|
Facility
|
OP
|
$857.00
|
|
|
Service Code
|
HCPCS 41800
|
| Hospital Charge Code |
76101665
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.46 |
| Max. Negotiated Rate |
$822.72 |
| Rate for Payer: Aetna Commercial |
$659.89
|
| Rate for Payer: Anthem Medicaid |
$294.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$668.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cash Price |
$428.50
|
| Rate for Payer: Cigna Commercial |
$711.31
|
| Rate for Payer: First Health Commercial |
$814.15
|
| Rate for Payer: Humana Commercial |
$728.45
|
| Rate for Payer: Humana KY Medicaid |
$294.72
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$297.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$702.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$632.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$300.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$754.16
|
| Rate for Payer: Ohio Health Group HMO |
$642.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$171.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$265.67
|
| Rate for Payer: PHCS Commercial |
$822.72
|
| Rate for Payer: United Healthcare All Payer |
$754.16
|
|
