|
DILANTIN (PHENYTOIN) 30MG/1CAP
|
Facility
|
OP
|
$9.49
|
|
|
Service Code
|
NDC 71374066
|
| Hospital Charge Code |
25000565
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$9.11 |
| Rate for Payer: Aetna Commercial |
$7.31
|
| Rate for Payer: Anthem Medicaid |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.40
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna Commercial |
$7.88
|
| Rate for Payer: First Health Commercial |
$9.02
|
| Rate for Payer: Humana Commercial |
$8.07
|
| Rate for Payer: Humana KY Medicaid |
$3.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.35
|
| Rate for Payer: Ohio Health Group HMO |
$7.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.55
|
| Rate for Payer: PHCS Commercial |
$9.11
|
| Rate for Payer: United Healthcare All Payer |
$8.35
|
|
|
DILANTIN (PHENYTOIN) 50MG/1TAB
|
Facility
|
OP
|
$4.62
|
|
|
Service Code
|
NDC 51672414601
|
| Hospital Charge Code |
25000566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem Medicaid |
$1.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Humana KY Medicaid |
$1.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
DILANTIN (PHENYTOIN) 50MG/1TAB
|
Facility
|
IP
|
$4.62
|
|
|
Service Code
|
NDC 51672414601
|
| Hospital Charge Code |
25000566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$4.44 |
| Rate for Payer: Aetna Commercial |
$3.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Cash Price |
$2.31
|
| Rate for Payer: Cigna Commercial |
$3.83
|
| Rate for Payer: First Health Commercial |
$4.39
|
| Rate for Payer: Humana Commercial |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.07
|
| Rate for Payer: Ohio Health Group HMO |
$3.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.19
|
| Rate for Payer: PHCS Commercial |
$4.44
|
| Rate for Payer: United Healthcare All Payer |
$4.07
|
|
|
DILANTIN TOTAL
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
30000043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$124.80 |
| Rate for Payer: Aetna Commercial |
$100.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.39
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$107.90
|
| Rate for Payer: First Health Commercial |
$123.50
|
| Rate for Payer: Humana Commercial |
$110.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.40
|
| Rate for Payer: Ohio Health Group HMO |
$97.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$113.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.70
|
| Rate for Payer: PHCS Commercial |
$124.80
|
| Rate for Payer: United Healthcare All Payer |
$114.40
|
|
|
DILANTIN TOTAL
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 80185
|
| Hospital Charge Code |
30000043
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$124.80 |
| Rate for Payer: Aetna Commercial |
$100.10
|
| Rate for Payer: Anthem Medicaid |
$13.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.25
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cash Price |
$65.00
|
| Rate for Payer: Cigna Commercial |
$107.90
|
| Rate for Payer: First Health Commercial |
$123.50
|
| Rate for Payer: Humana Commercial |
$110.50
|
| Rate for Payer: Humana KY Medicaid |
$13.25
|
| Rate for Payer: Humana Medicare Advantage |
$13.25
|
| Rate for Payer: Kentucky WC Medicaid |
$13.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$106.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$95.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$114.40
|
| Rate for Payer: Ohio Health Group HMO |
$97.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$113.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$89.70
|
| Rate for Payer: PHCS Commercial |
$124.80
|
| Rate for Payer: United Healthcare All Payer |
$114.40
|
|
|
DILATE ESOPHAGUS 1/MULT PAS(P
|
Professional
|
Both
|
$415.00
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
761P1776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.95 |
| Max. Negotiated Rate |
$249.00 |
| Rate for Payer: Aetna Commercial |
$134.60
|
| Rate for Payer: Ambetter Exchange |
$74.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.41
|
| Rate for Payer: Anthem Medicaid |
$59.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.34
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cash Price |
$207.50
|
| Rate for Payer: Cigna Commercial |
$120.81
|
| Rate for Payer: Healthspan PPO |
$192.05
|
| Rate for Payer: Humana Medicaid |
$59.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$74.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.15
|
| Rate for Payer: Molina Healthcare Passport |
$59.95
|
| Rate for Payer: Multiplan PHCS |
$249.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$96.78
|
| Rate for Payer: UHCCP Medicaid |
$79.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.45
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Professional
|
Both
|
$2,363.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
76101776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.95 |
| Max. Negotiated Rate |
$1,417.99 |
| Rate for Payer: Aetna Commercial |
$134.60
|
| Rate for Payer: Ambetter Exchange |
$74.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$75.41
|
| Rate for Payer: Anthem Medicaid |
$59.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$74.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$74.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$89.34
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cigna Commercial |
$120.81
|
| Rate for Payer: Healthspan PPO |
$192.05
|
| Rate for Payer: Humana Medicaid |
$59.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$116.57
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$74.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$74.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$61.15
|
| Rate for Payer: Molina Healthcare Passport |
$59.95
|
| Rate for Payer: Multiplan PHCS |
$1,417.99
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$96.78
|
| Rate for Payer: UHCCP Medicaid |
$79.18
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$74.45
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Facility
|
OP
|
$2,363.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
76101776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$812.75 |
| Max. Negotiated Rate |
$2,268.79 |
| Rate for Payer: Aetna Commercial |
$1,819.76
|
| Rate for Payer: Anthem Medicaid |
$812.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$866.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,843.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,212.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,169.49
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cigna Commercial |
$1,961.56
|
| Rate for Payer: First Health Commercial |
$2,245.15
|
| Rate for Payer: Humana Commercial |
$2,008.82
|
| Rate for Payer: Humana KY Medicaid |
$812.75
|
| Rate for Payer: Humana Medicare Advantage |
$866.29
|
| Rate for Payer: Kentucky WC Medicaid |
$821.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,937.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,744.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$829.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,079.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,772.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,890.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,056.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,630.69
|
| Rate for Payer: PHCS Commercial |
$2,268.79
|
| Rate for Payer: United Healthcare All Payer |
$2,079.72
|
|
|
DILATE ESOPHAGUS 1/MULT PASS
|
Facility
|
IP
|
$2,363.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
76101776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$709.00 |
| Max. Negotiated Rate |
$2,268.79 |
| Rate for Payer: Aetna Commercial |
$1,819.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,843.39
|
| Rate for Payer: Cash Price |
$1,181.66
|
| Rate for Payer: Cigna Commercial |
$1,961.56
|
| Rate for Payer: First Health Commercial |
$2,245.15
|
| Rate for Payer: Humana Commercial |
$2,008.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,937.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,744.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$709.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,079.72
|
| Rate for Payer: Ohio Health Group HMO |
$1,772.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,890.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,056.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,630.69
|
| Rate for Payer: PHCS Commercial |
$2,268.79
|
| Rate for Payer: United Healthcare All Payer |
$2,079.72
|
|
|
DILATE ESOPHAGUS 1/MULT PAS(T
|
Facility
|
OP
|
$1,948.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
761T1776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$670.03 |
| Max. Negotiated Rate |
$1,870.39 |
| Rate for Payer: Aetna Commercial |
$1,500.21
|
| Rate for Payer: Anthem Medicaid |
$670.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$866.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,212.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,169.49
|
| Rate for Payer: Cash Price |
$974.16
|
| Rate for Payer: Cash Price |
$974.16
|
| Rate for Payer: Cigna Commercial |
$1,617.11
|
| Rate for Payer: First Health Commercial |
$1,850.90
|
| Rate for Payer: Humana Commercial |
$1,656.07
|
| Rate for Payer: Humana KY Medicaid |
$670.03
|
| Rate for Payer: Humana Medicare Advantage |
$866.29
|
| Rate for Payer: Kentucky WC Medicaid |
$676.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,039.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$683.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,558.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,695.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,344.34
|
| Rate for Payer: PHCS Commercial |
$1,870.39
|
| Rate for Payer: United Healthcare All Payer |
$1,714.52
|
|
|
DILATE ESOPHAGUS 1/MULT PAS(T
|
Facility
|
IP
|
$1,948.32
|
|
|
Service Code
|
HCPCS 43450
|
| Hospital Charge Code |
761T1776
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$584.50 |
| Max. Negotiated Rate |
$1,870.39 |
| Rate for Payer: Aetna Commercial |
$1,500.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.69
|
| Rate for Payer: Cash Price |
$974.16
|
| Rate for Payer: Cigna Commercial |
$1,617.11
|
| Rate for Payer: First Health Commercial |
$1,850.90
|
| Rate for Payer: Humana Commercial |
$1,656.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,558.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,695.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,344.34
|
| Rate for Payer: PHCS Commercial |
$1,870.39
|
| Rate for Payer: United Healthcare All Payer |
$1,714.52
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
76102782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$90.30 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.69
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DILATE URETHRA STRICTURE
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
76102782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$103.51 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem Medicaid |
$103.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Humana KY Medicaid |
$103.51
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$104.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.69
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
DILATE URETHRA STRICTURE
|
Professional
|
Both
|
$301.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
76102782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.93 |
| Max. Negotiated Rate |
$180.60 |
| Rate for Payer: Aetna Commercial |
$88.86
|
| Rate for Payer: Ambetter Exchange |
$50.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.93
|
| Rate for Payer: Anthem Medicaid |
$37.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$50.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.58
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$127.60
|
| Rate for Payer: Healthspan PPO |
$107.00
|
| Rate for Payer: Humana Medicaid |
$37.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$50.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$38.01
|
| Rate for Payer: Molina Healthcare Passport |
$37.26
|
| Rate for Payer: Multiplan PHCS |
$180.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$65.62
|
| Rate for Payer: UHCCP Medicaid |
$33.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$50.48
|
|
|
DILATE URETHRA STRICTURE (P
|
Professional
|
Both
|
$110.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
761P2782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$31.93 |
| Max. Negotiated Rate |
$127.60 |
| Rate for Payer: Aetna Commercial |
$88.86
|
| Rate for Payer: Ambetter Exchange |
$50.48
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$31.93
|
| Rate for Payer: Anthem Medicaid |
$37.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$50.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$50.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$60.58
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna Commercial |
$127.60
|
| Rate for Payer: Healthspan PPO |
$107.00
|
| Rate for Payer: Humana Medicaid |
$37.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$72.42
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$50.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$38.01
|
| Rate for Payer: Molina Healthcare Passport |
$37.26
|
| Rate for Payer: Multiplan PHCS |
$66.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$65.62
|
| Rate for Payer: UHCCP Medicaid |
$33.53
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$37.63
|
| Rate for Payer: Wellcare Medicare Advantage |
$50.48
|
|
|
DILATE URETHRA STRICTURE (T
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
761T2782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$65.68 |
| Max. Negotiated Rate |
$183.36 |
| Rate for Payer: Aetna Commercial |
$147.07
|
| Rate for Payer: Anthem Medicaid |
$65.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$158.53
|
| Rate for Payer: First Health Commercial |
$181.45
|
| Rate for Payer: Humana Commercial |
$162.35
|
| Rate for Payer: Humana KY Medicaid |
$65.68
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$66.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.08
|
| Rate for Payer: Ohio Health Group HMO |
$143.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.79
|
| Rate for Payer: PHCS Commercial |
$183.36
|
| Rate for Payer: United Healthcare All Payer |
$168.08
|
|
|
DILATE URETHRA STRICTURE (T
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
HCPCS 53601
|
| Hospital Charge Code |
761T2782
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$57.30 |
| Max. Negotiated Rate |
$183.36 |
| Rate for Payer: Aetna Commercial |
$147.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.98
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$158.53
|
| Rate for Payer: First Health Commercial |
$181.45
|
| Rate for Payer: Humana Commercial |
$162.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.08
|
| Rate for Payer: Ohio Health Group HMO |
$143.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$166.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.79
|
| Rate for Payer: PHCS Commercial |
$183.36
|
| Rate for Payer: United Healthcare All Payer |
$168.08
|
|
|
DILATION AND CURETTAGE
|
Professional
|
Both
|
$875.00
|
|
|
Service Code
|
HCPCS 58120
|
| Hospital Charge Code |
76102208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$135.00 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Aetna Commercial |
$325.78
|
| Rate for Payer: Ambetter Exchange |
$220.45
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$135.00
|
| Rate for Payer: Anthem Medicaid |
$157.92
|
| Rate for Payer: Buckeye Individual/Medicaid |
$220.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$220.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$264.54
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$318.31
|
| Rate for Payer: Healthspan PPO |
$361.06
|
| Rate for Payer: Humana Medicaid |
$157.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$282.38
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$220.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$161.08
|
| Rate for Payer: Molina Healthcare Passport |
$157.92
|
| Rate for Payer: Multiplan PHCS |
$525.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$286.58
|
| Rate for Payer: UHCCP Medicaid |
$141.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$159.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$220.45
|
|
|
DILATION AND CURETTAGE
|
Facility
|
IP
|
$875.00
|
|
|
Service Code
|
HCPCS 58120
|
| Hospital Charge Code |
76102208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$840.00 |
| Rate for Payer: Aetna Commercial |
$673.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$682.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$726.25
|
| Rate for Payer: First Health Commercial |
$831.25
|
| Rate for Payer: Humana Commercial |
$743.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$717.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$770.00
|
| Rate for Payer: Ohio Health Group HMO |
$656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$761.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.75
|
| Rate for Payer: PHCS Commercial |
$840.00
|
| Rate for Payer: United Healthcare All Payer |
$770.00
|
|
|
DILATION AND CURETTAGE
|
Facility
|
OP
|
$875.00
|
|
|
Service Code
|
HCPCS 58120
|
| Hospital Charge Code |
76102208
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$300.91 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Aetna Commercial |
$673.75
|
| Rate for Payer: Anthem Medicaid |
$300.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$682.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$726.25
|
| Rate for Payer: First Health Commercial |
$831.25
|
| Rate for Payer: Humana Commercial |
$743.75
|
| Rate for Payer: Humana KY Medicaid |
$300.91
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$303.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$717.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$645.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$306.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$770.00
|
| Rate for Payer: Ohio Health Group HMO |
$656.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$761.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$603.75
|
| Rate for Payer: PHCS Commercial |
$840.00
|
| Rate for Payer: United Healthcare All Payer |
$770.00
|
|
|
DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC (NONOBSTETRICAL)
|
Facility
|
OP
|
$4,112.95
|
|
|
Service Code
|
CPT 58120
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,937.82 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
|
|
DILATION OF ANAL SPHINCTER (SE
|
Professional
|
Both
|
$685.00
|
|
|
Service Code
|
HCPCS 45905
|
| Hospital Charge Code |
76101907
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$411.00 |
| Rate for Payer: Aetna Commercial |
$237.72
|
| Rate for Payer: Ambetter Exchange |
$161.10
|
| Rate for Payer: Anthem Medicaid |
$66.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$193.32
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cigna Commercial |
$220.85
|
| Rate for Payer: Healthspan PPO |
$200.47
|
| Rate for Payer: Humana Medicaid |
$66.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$210.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$161.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.60
|
| Rate for Payer: Molina Healthcare Passport |
$66.27
|
| Rate for Payer: Multiplan PHCS |
$411.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$209.43
|
| Rate for Payer: UHCCP Medicaid |
$239.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.10
|
|
|
DILATION OF ANAL SPHINCTER (SE
|
Facility
|
OP
|
$685.00
|
|
|
Service Code
|
HCPCS 45905
|
| Hospital Charge Code |
76101907
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$235.57 |
| Max. Negotiated Rate |
$1,525.23 |
| Rate for Payer: Aetna Commercial |
$527.45
|
| Rate for Payer: Anthem Medicaid |
$235.57
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,089.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$534.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,525.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,470.76
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cigna Commercial |
$568.55
|
| Rate for Payer: First Health Commercial |
$650.75
|
| Rate for Payer: Humana Commercial |
$582.25
|
| Rate for Payer: Humana KY Medicaid |
$235.57
|
| Rate for Payer: Humana Medicare Advantage |
$1,089.45
|
| Rate for Payer: Kentucky WC Medicaid |
$237.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$561.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$505.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,307.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$240.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$602.80
|
| Rate for Payer: Ohio Health Group HMO |
$513.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$548.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$595.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.65
|
| Rate for Payer: PHCS Commercial |
$657.60
|
| Rate for Payer: United Healthcare All Payer |
$602.80
|
|
|
DILATION OF ANAL SPHINCTER (SE
|
Facility
|
IP
|
$685.00
|
|
|
Service Code
|
HCPCS 45905
|
| Hospital Charge Code |
76101907
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$205.50 |
| Max. Negotiated Rate |
$657.60 |
| Rate for Payer: Aetna Commercial |
$527.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$534.30
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cigna Commercial |
$568.55
|
| Rate for Payer: First Health Commercial |
$650.75
|
| Rate for Payer: Humana Commercial |
$582.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$561.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$505.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$205.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$602.80
|
| Rate for Payer: Ohio Health Group HMO |
$513.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$548.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$595.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$472.65
|
| Rate for Payer: PHCS Commercial |
$657.60
|
| Rate for Payer: United Healthcare All Payer |
$602.80
|
|
|
DILATION OF ANAL SPHINCTER (SE
|
Professional
|
Both
|
$685.00
|
|
|
Service Code
|
HCPCS 45905
|
| Hospital Charge Code |
761P1907
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$66.27 |
| Max. Negotiated Rate |
$411.00 |
| Rate for Payer: Aetna Commercial |
$237.72
|
| Rate for Payer: Ambetter Exchange |
$161.10
|
| Rate for Payer: Anthem Medicaid |
$66.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$161.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$193.32
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cash Price |
$342.50
|
| Rate for Payer: Cigna Commercial |
$220.85
|
| Rate for Payer: Healthspan PPO |
$200.47
|
| Rate for Payer: Humana Medicaid |
$66.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$210.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$161.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.60
|
| Rate for Payer: Molina Healthcare Passport |
$66.27
|
| Rate for Payer: Multiplan PHCS |
$411.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$209.43
|
| Rate for Payer: UHCCP Medicaid |
$239.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$161.10
|
|
