|
DES MAL LES 3.1-4CM(T
|
Facility
|
OP
|
$712.00
|
|
|
Service Code
|
HCPCS 17284
|
| Hospital Charge Code |
761T0270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$244.86 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem Medicaid |
$244.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Humana KY Medicaid |
$244.86
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$249.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$619.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$491.28
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES > 4CM
|
Facility
|
IP
|
$1,562.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
76100271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$468.60 |
| Max. Negotiated Rate |
$1,499.52 |
| Rate for Payer: Aetna Commercial |
$1,202.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,218.36
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: First Health Commercial |
$1,483.90
|
| Rate for Payer: Humana Commercial |
$1,327.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,280.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,152.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,374.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,171.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,249.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,358.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,077.78
|
| Rate for Payer: PHCS Commercial |
$1,499.52
|
| Rate for Payer: United Healthcare All Payer |
$1,374.56
|
|
|
DES MAL LES > 4CM
|
Professional
|
Both
|
$1,562.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
76100271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$937.20 |
| Rate for Payer: Aetna Commercial |
$411.38
|
| Rate for Payer: Ambetter Exchange |
$256.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$183.00
|
| Rate for Payer: Anthem Medicaid |
$259.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$256.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$256.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$307.45
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$462.60
|
| Rate for Payer: Healthspan PPO |
$401.68
|
| Rate for Payer: Humana Medicaid |
$259.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$361.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$256.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$264.46
|
| Rate for Payer: Molina Healthcare Passport |
$259.27
|
| Rate for Payer: Multiplan PHCS |
$937.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$333.07
|
| Rate for Payer: UHCCP Medicaid |
$192.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$261.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$256.21
|
|
|
DES MAL LES > 4CM
|
Facility
|
OP
|
$1,562.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
76100271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$537.17 |
| Max. Negotiated Rate |
$1,499.52 |
| Rate for Payer: Aetna Commercial |
$1,202.74
|
| Rate for Payer: Anthem Medicaid |
$537.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,218.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: First Health Commercial |
$1,483.90
|
| Rate for Payer: Humana Commercial |
$1,327.70
|
| Rate for Payer: Humana KY Medicaid |
$537.17
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$542.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,280.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,152.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$547.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,374.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,171.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,249.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,358.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,077.78
|
| Rate for Payer: PHCS Commercial |
$1,499.52
|
| Rate for Payer: United Healthcare All Payer |
$1,374.56
|
|
|
DES MAL LES > 4CM(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
761P0271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna Commercial |
$411.38
|
| Rate for Payer: Ambetter Exchange |
$256.21
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$183.00
|
| Rate for Payer: Anthem Medicaid |
$259.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$256.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$256.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$307.45
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$462.60
|
| Rate for Payer: Healthspan PPO |
$401.68
|
| Rate for Payer: Humana Medicaid |
$259.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$361.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$256.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$264.46
|
| Rate for Payer: Molina Healthcare Passport |
$259.27
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$333.07
|
| Rate for Payer: UHCCP Medicaid |
$192.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$261.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$256.21
|
|
|
DES MAL LES > 4CM(T
|
Facility
|
OP
|
$712.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
761T0271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$244.86 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem Medicaid |
$244.86
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Humana KY Medicaid |
$244.86
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$247.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$249.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$619.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$491.28
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES > 4CM(T
|
Facility
|
IP
|
$712.00
|
|
|
Service Code
|
HCPCS 17286
|
| Hospital Charge Code |
761T0271
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$213.60 |
| Max. Negotiated Rate |
$683.52 |
| Rate for Payer: Aetna Commercial |
$548.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$555.36
|
| Rate for Payer: Cash Price |
$356.00
|
| Rate for Payer: Cigna Commercial |
$590.96
|
| Rate for Payer: First Health Commercial |
$676.40
|
| Rate for Payer: Humana Commercial |
$605.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$583.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$525.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$626.56
|
| Rate for Payer: Ohio Health Group HMO |
$534.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$569.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$619.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$491.28
|
| Rate for Payer: PHCS Commercial |
$683.52
|
| Rate for Payer: United Healthcare All Payer |
$626.56
|
|
|
DES MAL LES .6-1.0CM SNHF
|
Professional
|
Both
|
$588.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
76100261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$352.80 |
| Rate for Payer: Aetna Commercial |
$155.14
|
| Rate for Payer: Ambetter Exchange |
$99.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.26
|
| Rate for Payer: Anthem Medicaid |
$93.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$99.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$99.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$118.88
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cigna Commercial |
$193.97
|
| Rate for Payer: Healthspan PPO |
$177.11
|
| Rate for Payer: Humana Medicaid |
$93.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$99.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.94
|
| Rate for Payer: Molina Healthcare Passport |
$93.08
|
| Rate for Payer: Multiplan PHCS |
$352.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$128.79
|
| Rate for Payer: UHCCP Medicaid |
$68.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$99.07
|
|
|
DES MAL LES .6-1.0CM SNHF
|
Facility
|
IP
|
$588.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
76100261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$176.40 |
| Max. Negotiated Rate |
$564.48 |
| Rate for Payer: Aetna Commercial |
$452.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$458.64
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cigna Commercial |
$488.04
|
| Rate for Payer: First Health Commercial |
$558.60
|
| Rate for Payer: Humana Commercial |
$499.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$482.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$433.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$176.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$517.44
|
| Rate for Payer: Ohio Health Group HMO |
$441.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$470.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$405.72
|
| Rate for Payer: PHCS Commercial |
$564.48
|
| Rate for Payer: United Healthcare All Payer |
$517.44
|
|
|
DES MAL LES .6-1.0CM SNHF
|
Facility
|
OP
|
$588.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
76100261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.59 |
| Max. Negotiated Rate |
$564.48 |
| Rate for Payer: Aetna Commercial |
$452.76
|
| Rate for Payer: Anthem Medicaid |
$202.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$458.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cash Price |
$294.00
|
| Rate for Payer: Cigna Commercial |
$488.04
|
| Rate for Payer: First Health Commercial |
$558.60
|
| Rate for Payer: Humana Commercial |
$499.80
|
| Rate for Payer: Humana KY Medicaid |
$202.21
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$204.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$482.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$433.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$206.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$517.44
|
| Rate for Payer: Ohio Health Group HMO |
$441.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$470.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$405.72
|
| Rate for Payer: PHCS Commercial |
$564.48
|
| Rate for Payer: United Healthcare All Payer |
$517.44
|
|
|
DES MAL LES .6-1.0CM SNHF(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
761P0261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$193.97 |
| Rate for Payer: Aetna Commercial |
$155.14
|
| Rate for Payer: Ambetter Exchange |
$99.07
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$65.26
|
| Rate for Payer: Anthem Medicaid |
$93.08
|
| Rate for Payer: Buckeye Individual/Medicaid |
$99.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$99.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$118.88
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$193.97
|
| Rate for Payer: Healthspan PPO |
$177.11
|
| Rate for Payer: Humana Medicaid |
$93.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$140.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$99.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.07
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.94
|
| Rate for Payer: Molina Healthcare Passport |
$93.08
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$128.79
|
| Rate for Payer: UHCCP Medicaid |
$68.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.01
|
| Rate for Payer: Wellcare Medicare Advantage |
$99.07
|
|
|
DES MAL LES .6-1.0CM SNHF(T
|
Facility
|
OP
|
$288.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
761T0261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.04 |
| Max. Negotiated Rate |
$276.48 |
| Rate for Payer: Aetna Commercial |
$221.76
|
| Rate for Payer: Anthem Medicaid |
$99.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$224.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$239.04
|
| Rate for Payer: First Health Commercial |
$273.60
|
| Rate for Payer: Humana Commercial |
$244.80
|
| Rate for Payer: Humana KY Medicaid |
$99.04
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$100.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$236.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$101.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.44
|
| Rate for Payer: Ohio Health Group HMO |
$216.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.72
|
| Rate for Payer: PHCS Commercial |
$276.48
|
| Rate for Payer: United Healthcare All Payer |
$253.44
|
|
|
DES MAL LES .6-1.0CM SNHF(T
|
Facility
|
IP
|
$288.00
|
|
|
Service Code
|
HCPCS 17271
|
| Hospital Charge Code |
761T0261
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.40 |
| Max. Negotiated Rate |
$276.48 |
| Rate for Payer: Aetna Commercial |
$221.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$224.64
|
| Rate for Payer: Cash Price |
$144.00
|
| Rate for Payer: Cigna Commercial |
$239.04
|
| Rate for Payer: First Health Commercial |
$273.60
|
| Rate for Payer: Humana Commercial |
$244.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$236.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$212.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$253.44
|
| Rate for Payer: Ohio Health Group HMO |
$216.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$198.72
|
| Rate for Payer: PHCS Commercial |
$276.48
|
| Rate for Payer: United Healthcare All Payer |
$253.44
|
|
|
DESMOPRESSIN 0.1MG TABLET
|
Facility
|
OP
|
$9.05
|
|
|
Service Code
|
NDC 69918010101
|
| Hospital Charge Code |
25003743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem Medicaid |
$3.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Humana KY Medicaid |
$3.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
DESMOPRESSIN 0.1MG TABLET
|
Facility
|
IP
|
$9.05
|
|
|
Service Code
|
NDC 69918010101
|
| Hospital Charge Code |
25003743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.71 |
| Max. Negotiated Rate |
$8.69 |
| Rate for Payer: Aetna Commercial |
$6.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.06
|
| Rate for Payer: Cash Price |
$4.53
|
| Rate for Payer: Cigna Commercial |
$7.51
|
| Rate for Payer: First Health Commercial |
$8.60
|
| Rate for Payer: Humana Commercial |
$7.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.96
|
| Rate for Payer: Ohio Health Group HMO |
$6.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.24
|
| Rate for Payer: PHCS Commercial |
$8.69
|
| Rate for Payer: United Healthcare All Payer |
$7.96
|
|
|
DESMOPRESSIN1MCG[4MCG/1MLV10ML
|
Facility
|
IP
|
$975.00
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
25002322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$760.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$809.25
|
| Rate for Payer: First Health Commercial |
$926.25
|
| Rate for Payer: Humana Commercial |
$828.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$799.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$719.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$292.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$858.00
|
| Rate for Payer: Ohio Health Group HMO |
$731.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.75
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
DESMOPRESSIN1MCG[4MCG/1MLV10ML
|
Facility
|
OP
|
$975.00
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
25002322
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem Medicaid |
$335.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$760.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.25
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$809.25
|
| Rate for Payer: First Health Commercial |
$926.25
|
| Rate for Payer: Humana Commercial |
$828.75
|
| Rate for Payer: Humana KY Medicaid |
$335.30
|
| Rate for Payer: Humana Medicare Advantage |
$3.89
|
| Rate for Payer: Kentucky WC Medicaid |
$338.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$799.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$719.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$342.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$858.00
|
| Rate for Payer: Ohio Health Group HMO |
$731.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.75
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
DESMOPRESSIN 1MCG (4MCG SDV)
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
25002321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$58.20 |
| Max. Negotiated Rate |
$186.24 |
| Rate for Payer: Aetna Commercial |
$149.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$151.32
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$161.02
|
| Rate for Payer: First Health Commercial |
$184.30
|
| Rate for Payer: Humana Commercial |
$164.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$170.72
|
| Rate for Payer: Ohio Health Group HMO |
$145.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.86
|
| Rate for Payer: PHCS Commercial |
$186.24
|
| Rate for Payer: United Healthcare All Payer |
$170.72
|
|
|
DESMOPRESSIN 1MCG (4MCG SDV)
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
HCPCS J2597
|
| Hospital Charge Code |
25002321
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.89 |
| Max. Negotiated Rate |
$186.24 |
| Rate for Payer: Aetna Commercial |
$149.38
|
| Rate for Payer: Anthem Medicaid |
$66.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$151.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.25
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cash Price |
$97.00
|
| Rate for Payer: Cigna Commercial |
$161.02
|
| Rate for Payer: First Health Commercial |
$184.30
|
| Rate for Payer: Humana Commercial |
$164.90
|
| Rate for Payer: Humana KY Medicaid |
$66.72
|
| Rate for Payer: Humana Medicare Advantage |
$3.89
|
| Rate for Payer: Kentucky WC Medicaid |
$67.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$159.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$143.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$68.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$170.72
|
| Rate for Payer: Ohio Health Group HMO |
$145.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$168.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$133.86
|
| Rate for Payer: PHCS Commercial |
$186.24
|
| Rate for Payer: United Healthcare All Payer |
$170.72
|
|
|
DESONIDE 0.05% CREAM 15 GRAM
|
Facility
|
IP
|
$6.29
|
|
|
Service Code
|
NDC 51672128001
|
| Hospital Charge Code |
25002988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.91
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna Commercial |
$5.22
|
| Rate for Payer: First Health Commercial |
$5.98
|
| Rate for Payer: Humana Commercial |
$5.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.54
|
| Rate for Payer: Ohio Health Group HMO |
$4.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.34
|
| Rate for Payer: PHCS Commercial |
$6.04
|
| Rate for Payer: United Healthcare All Payer |
$5.54
|
|
|
DESONIDE 0.05% CREAM 15 GRAM
|
Facility
|
OP
|
$6.29
|
|
|
Service Code
|
NDC 51672128001
|
| Hospital Charge Code |
25002988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$6.04 |
| Rate for Payer: Aetna Commercial |
$4.84
|
| Rate for Payer: Anthem Medicaid |
$2.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.91
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna Commercial |
$5.22
|
| Rate for Payer: First Health Commercial |
$5.98
|
| Rate for Payer: Humana Commercial |
$5.35
|
| Rate for Payer: Humana KY Medicaid |
$2.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$5.54
|
| Rate for Payer: Ohio Health Group HMO |
$4.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.34
|
| Rate for Payer: PHCS Commercial |
$6.04
|
| Rate for Payer: United Healthcare All Payer |
$5.54
|
|
|
DESONIDE 0.05% OINT(60GM)
|
Facility
|
OP
|
$5.21
|
|
|
Service Code
|
NDC 45802042337
|
| Hospital Charge Code |
25000543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.01
|
| Rate for Payer: Anthem Medicaid |
$1.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.06
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.32
|
| Rate for Payer: First Health Commercial |
$4.95
|
| Rate for Payer: Humana Commercial |
$4.43
|
| Rate for Payer: Humana KY Medicaid |
$1.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.58
|
| Rate for Payer: Ohio Health Group HMO |
$3.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.59
|
| Rate for Payer: PHCS Commercial |
$5.00
|
| Rate for Payer: United Healthcare All Payer |
$4.58
|
|
|
DESONIDE 0.05% OINT(60GM)
|
Facility
|
IP
|
$5.21
|
|
|
Service Code
|
NDC 45802042337
|
| Hospital Charge Code |
25000543
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.56 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Aetna Commercial |
$4.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.06
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.32
|
| Rate for Payer: First Health Commercial |
$4.95
|
| Rate for Payer: Humana Commercial |
$4.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.58
|
| Rate for Payer: Ohio Health Group HMO |
$3.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.59
|
| Rate for Payer: PHCS Commercial |
$5.00
|
| Rate for Payer: United Healthcare All Payer |
$4.58
|
|
|
DEST ANY METHOD 1ST LESION
|
Facility
|
IP
|
$428.00
|
|
|
Service Code
|
HCPCS 17000
|
| Hospital Charge Code |
76100247
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$128.40 |
| Max. Negotiated Rate |
$410.88 |
| Rate for Payer: Aetna Commercial |
$329.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$333.84
|
| Rate for Payer: Cash Price |
$214.00
|
| Rate for Payer: Cigna Commercial |
$355.24
|
| Rate for Payer: First Health Commercial |
$406.60
|
| Rate for Payer: Humana Commercial |
$363.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$350.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$315.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$128.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$376.64
|
| Rate for Payer: Ohio Health Group HMO |
$321.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$342.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$372.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$295.32
|
| Rate for Payer: PHCS Commercial |
$410.88
|
| Rate for Payer: United Healthcare All Payer |
$376.64
|
|
|
DEST ANY METHOD 1ST LESION
|
Facility
|
OP
|
$428.00
|
|
|
Service Code
|
HCPCS 17000
|
| Hospital Charge Code |
76100247
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$147.19 |
| Max. Negotiated Rate |
$410.88 |
| Rate for Payer: Aetna Commercial |
$329.56
|
| Rate for Payer: Anthem Medicaid |
$147.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$333.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$214.00
|
| Rate for Payer: Cash Price |
$214.00
|
| Rate for Payer: Cigna Commercial |
$355.24
|
| Rate for Payer: First Health Commercial |
$406.60
|
| Rate for Payer: Humana Commercial |
$363.80
|
| Rate for Payer: Humana KY Medicaid |
$147.19
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$148.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$350.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$315.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$150.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$376.64
|
| Rate for Payer: Ohio Health Group HMO |
$321.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$342.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$372.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$295.32
|
| Rate for Payer: PHCS Commercial |
$410.88
|
| Rate for Payer: United Healthcare All Payer |
$376.64
|
|
