|
DILAT XST TRC NEW ACCESS RCS
|
Professional
|
Both
|
$590.00
|
|
|
Service Code
|
HCPCS 50437
|
| Hospital Charge Code |
76103030
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$206.50 |
| Max. Negotiated Rate |
$420.42 |
| Rate for Payer: Ambetter Exchange |
$235.84
|
| Rate for Payer: Anthem Medicaid |
$206.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$235.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$235.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$283.01
|
| Rate for Payer: Cash Price |
$295.00
|
| Rate for Payer: Cash Price |
$295.00
|
| Rate for Payer: Cigna Commercial |
$420.42
|
| Rate for Payer: Humana Medicaid |
$206.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$346.03
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$235.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$235.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$210.93
|
| Rate for Payer: Molina Healthcare Passport |
$206.79
|
| Rate for Payer: Multiplan PHCS |
$354.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$306.59
|
| Rate for Payer: UHCCP Medicaid |
$206.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$208.86
|
| Rate for Payer: Wellcare Medicare Advantage |
$235.84
|
|
|
DILAUDID 0.1MG(0.5MG/0.5ML)SYR
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25004542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Kentucky WC Medicaid |
$26.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
DILAUDID 0.1MG(0.5MG/0.5ML)SYR
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25004542
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
DILAUDID [0.1MG] 1MG/1ML VIAL
|
Facility
|
IP
|
$77.60
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.28 |
| Max. Negotiated Rate |
$74.50 |
| Rate for Payer: Aetna Commercial |
$59.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.53
|
| Rate for Payer: Cash Price |
$38.80
|
| Rate for Payer: Cigna Commercial |
$64.41
|
| Rate for Payer: First Health Commercial |
$73.72
|
| Rate for Payer: Humana Commercial |
$65.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.29
|
| Rate for Payer: Ohio Health Group HMO |
$58.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.54
|
| Rate for Payer: PHCS Commercial |
$74.50
|
| Rate for Payer: United Healthcare All Payer |
$68.29
|
|
|
DILAUDID [0.1MG] 1MG/1ML VIAL
|
Facility
|
OP
|
$77.60
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002026
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.28 |
| Max. Negotiated Rate |
$74.50 |
| Rate for Payer: Aetna Commercial |
$59.75
|
| Rate for Payer: Anthem Medicaid |
$26.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.53
|
| Rate for Payer: Cash Price |
$38.80
|
| Rate for Payer: Cigna Commercial |
$64.41
|
| Rate for Payer: First Health Commercial |
$73.72
|
| Rate for Payer: Humana Commercial |
$65.96
|
| Rate for Payer: Humana KY Medicaid |
$26.69
|
| Rate for Payer: Kentucky WC Medicaid |
$26.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.29
|
| Rate for Payer: Ohio Health Group HMO |
$58.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.54
|
| Rate for Payer: PHCS Commercial |
$74.50
|
| Rate for Payer: United Healthcare All Payer |
$68.29
|
|
|
DILAUDID [0.1MG] 2MG/1ML VIAL
|
Facility
|
IP
|
$78.37
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.13
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.05
|
| Rate for Payer: First Health Commercial |
$74.45
|
| Rate for Payer: Humana Commercial |
$66.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
DILAUDID [0.1MG] 2MG/1ML VIAL
|
Facility
|
OP
|
$78.37
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.51 |
| Max. Negotiated Rate |
$75.24 |
| Rate for Payer: Aetna Commercial |
$60.34
|
| Rate for Payer: Anthem Medicaid |
$26.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61.13
|
| Rate for Payer: Cash Price |
$39.19
|
| Rate for Payer: Cigna Commercial |
$65.05
|
| Rate for Payer: First Health Commercial |
$74.45
|
| Rate for Payer: Humana Commercial |
$66.61
|
| Rate for Payer: Humana KY Medicaid |
$26.95
|
| Rate for Payer: Kentucky WC Medicaid |
$27.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.51
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.97
|
| Rate for Payer: Ohio Health Group HMO |
$58.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$54.08
|
| Rate for Payer: PHCS Commercial |
$75.24
|
| Rate for Payer: United Healthcare All Payer |
$68.97
|
|
|
DILAUDID 0.1MG 40MG/20ML VIAL
|
Facility
|
IP
|
$128.43
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$123.29 |
| Rate for Payer: Aetna Commercial |
$98.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.18
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cigna Commercial |
$106.60
|
| Rate for Payer: First Health Commercial |
$122.01
|
| Rate for Payer: Humana Commercial |
$109.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.02
|
| Rate for Payer: Ohio Health Group HMO |
$96.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.62
|
| Rate for Payer: PHCS Commercial |
$123.29
|
| Rate for Payer: United Healthcare All Payer |
$113.02
|
|
|
DILAUDID 0.1MG 40MG/20ML VIAL
|
Facility
|
OP
|
$128.43
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002024
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$123.29 |
| Rate for Payer: Aetna Commercial |
$98.89
|
| Rate for Payer: Anthem Medicaid |
$44.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$100.18
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cigna Commercial |
$106.60
|
| Rate for Payer: First Health Commercial |
$122.01
|
| Rate for Payer: Humana Commercial |
$109.17
|
| Rate for Payer: Humana KY Medicaid |
$44.17
|
| Rate for Payer: Kentucky WC Medicaid |
$44.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$105.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$94.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$113.02
|
| Rate for Payer: Ohio Health Group HMO |
$96.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$111.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.62
|
| Rate for Payer: PHCS Commercial |
$123.29
|
| Rate for Payer: United Healthcare All Payer |
$113.02
|
|
|
DILAUDID 0.1MG 4MG/1ML TUBEX
|
Facility
|
OP
|
$78.15
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.45 |
| Max. Negotiated Rate |
$75.02 |
| Rate for Payer: Aetna Commercial |
$60.18
|
| Rate for Payer: Anthem Medicaid |
$26.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.96
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.86
|
| Rate for Payer: First Health Commercial |
$74.24
|
| Rate for Payer: Humana Commercial |
$66.43
|
| Rate for Payer: Humana KY Medicaid |
$26.88
|
| Rate for Payer: Kentucky WC Medicaid |
$27.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.77
|
| Rate for Payer: Ohio Health Group HMO |
$58.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.92
|
| Rate for Payer: PHCS Commercial |
$75.02
|
| Rate for Payer: United Healthcare All Payer |
$68.77
|
|
|
DILAUDID 0.1MG 4MG/1ML TUBEX
|
Facility
|
IP
|
$78.15
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.45 |
| Max. Negotiated Rate |
$75.02 |
| Rate for Payer: Aetna Commercial |
$60.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.96
|
| Rate for Payer: Cash Price |
$39.08
|
| Rate for Payer: Cigna Commercial |
$64.86
|
| Rate for Payer: First Health Commercial |
$74.24
|
| Rate for Payer: Humana Commercial |
$66.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.77
|
| Rate for Payer: Ohio Health Group HMO |
$58.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.92
|
| Rate for Payer: PHCS Commercial |
$75.02
|
| Rate for Payer: United Healthcare All Payer |
$68.77
|
|
|
DILAUDID 0.1 MG(500MG/50ML VL)
|
Facility
|
IP
|
$178.50
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$171.36 |
| Rate for Payer: Aetna Commercial |
$137.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.23
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Cigna Commercial |
$148.16
|
| Rate for Payer: First Health Commercial |
$169.57
|
| Rate for Payer: Humana Commercial |
$151.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.08
|
| Rate for Payer: Ohio Health Group HMO |
$133.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.17
|
| Rate for Payer: PHCS Commercial |
$171.36
|
| Rate for Payer: United Healthcare All Payer |
$157.08
|
|
|
DILAUDID 0.1 MG(500MG/50ML VL)
|
Facility
|
OP
|
$178.50
|
|
|
Service Code
|
HCPCS J1171
|
| Hospital Charge Code |
25002028
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.55 |
| Max. Negotiated Rate |
$171.36 |
| Rate for Payer: Aetna Commercial |
$137.44
|
| Rate for Payer: Anthem Medicaid |
$61.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.23
|
| Rate for Payer: Cash Price |
$89.25
|
| Rate for Payer: Cigna Commercial |
$148.16
|
| Rate for Payer: First Health Commercial |
$169.57
|
| Rate for Payer: Humana Commercial |
$151.72
|
| Rate for Payer: Humana KY Medicaid |
$61.39
|
| Rate for Payer: Kentucky WC Medicaid |
$62.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$131.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$62.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.08
|
| Rate for Payer: Ohio Health Group HMO |
$133.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$142.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$155.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$123.17
|
| Rate for Payer: PHCS Commercial |
$171.36
|
| Rate for Payer: United Healthcare All Payer |
$157.08
|
|
|
DILAUDID(HYDROM)SUPPO 3MG/1EA
|
Facility
|
OP
|
$69.81
|
|
|
Service Code
|
NDC 574722406
|
| Hospital Charge Code |
25002777
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.94 |
| Max. Negotiated Rate |
$67.02 |
| Rate for Payer: Aetna Commercial |
$53.75
|
| Rate for Payer: Anthem Medicaid |
$24.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.45
|
| Rate for Payer: Cash Price |
$34.91
|
| Rate for Payer: Cigna Commercial |
$57.94
|
| Rate for Payer: First Health Commercial |
$66.32
|
| Rate for Payer: Humana Commercial |
$59.34
|
| Rate for Payer: Humana KY Medicaid |
$24.01
|
| Rate for Payer: Kentucky WC Medicaid |
$24.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.43
|
| Rate for Payer: Ohio Health Group HMO |
$52.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.17
|
| Rate for Payer: PHCS Commercial |
$67.02
|
| Rate for Payer: United Healthcare All Payer |
$61.43
|
|
|
DILAUDID(HYDROM)SUPPO 3MG/1EA
|
Facility
|
IP
|
$69.81
|
|
|
Service Code
|
NDC 574722406
|
| Hospital Charge Code |
25002777
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.94 |
| Max. Negotiated Rate |
$67.02 |
| Rate for Payer: Aetna Commercial |
$53.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54.45
|
| Rate for Payer: Cash Price |
$34.91
|
| Rate for Payer: Cigna Commercial |
$57.94
|
| Rate for Payer: First Health Commercial |
$66.32
|
| Rate for Payer: Humana Commercial |
$59.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$61.43
|
| Rate for Payer: Ohio Health Group HMO |
$52.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48.17
|
| Rate for Payer: PHCS Commercial |
$67.02
|
| Rate for Payer: United Healthcare All Payer |
$61.43
|
|
|
DIL FEM URT WSUPP/INSTLJ SBS(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
761P2121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna Commercial |
$66.53
|
| Rate for Payer: Ambetter Exchange |
$37.75
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.42
|
| Rate for Payer: Anthem Medicaid |
$28.56
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$45.30
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Healthspan PPO |
$91.71
|
| Rate for Payer: Humana Medicaid |
$28.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$37.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.13
|
| Rate for Payer: Molina Healthcare Passport |
$28.56
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.08
|
| Rate for Payer: UHCCP Medicaid |
$25.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.75
|
|
|
DIL FEM URT WSUPP/INSTLJ SBSQ
|
Facility
|
OP
|
$540.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
76102121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem Medicaid |
$185.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Humana KY Medicaid |
$185.71
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$187.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$432.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.60
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
DIL FEM URT WSUPP/INSTLJ SBSQ
|
Professional
|
Both
|
$540.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
76102121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$24.42 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna Commercial |
$66.53
|
| Rate for Payer: Ambetter Exchange |
$37.75
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$24.42
|
| Rate for Payer: Anthem Medicaid |
$28.56
|
| Rate for Payer: Buckeye Individual/Medicaid |
$37.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$37.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$45.30
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Healthspan PPO |
$91.71
|
| Rate for Payer: Humana Medicaid |
$28.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$55.05
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$37.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$29.13
|
| Rate for Payer: Molina Healthcare Passport |
$28.56
|
| Rate for Payer: Multiplan PHCS |
$324.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$49.08
|
| Rate for Payer: UHCCP Medicaid |
$25.64
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.85
|
| Rate for Payer: Wellcare Medicare Advantage |
$37.75
|
|
|
DIL FEM URT WSUPP/INSTLJ SBSQ
|
Facility
|
IP
|
$540.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
76102121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$518.40 |
| Rate for Payer: Aetna Commercial |
$415.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.20
|
| Rate for Payer: Cash Price |
$270.00
|
| Rate for Payer: Cigna Commercial |
$448.20
|
| Rate for Payer: First Health Commercial |
$513.00
|
| Rate for Payer: Humana Commercial |
$459.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$442.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.20
|
| Rate for Payer: Ohio Health Group HMO |
$405.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$432.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.60
|
| Rate for Payer: PHCS Commercial |
$518.40
|
| Rate for Payer: United Healthcare All Payer |
$475.20
|
|
|
DIL FEM URT WSUPP/INSTLJ SBS(T
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
761T2121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.74 |
| Max. Negotiated Rate |
$166.74 |
| Rate for Payer: Aetna Commercial |
$127.05
|
| Rate for Payer: Anthem Medicaid |
$56.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$119.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$166.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$160.78
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$136.95
|
| Rate for Payer: First Health Commercial |
$156.75
|
| Rate for Payer: Humana Commercial |
$140.25
|
| Rate for Payer: Humana KY Medicaid |
$56.74
|
| Rate for Payer: Humana Medicare Advantage |
$119.10
|
| Rate for Payer: Kentucky WC Medicaid |
$57.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$145.20
|
| Rate for Payer: Ohio Health Group HMO |
$123.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.85
|
| Rate for Payer: PHCS Commercial |
$158.40
|
| Rate for Payer: United Healthcare All Payer |
$145.20
|
|
|
DIL FEM URT WSUPP/INSTLJ SBS(T
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
HCPCS 53661
|
| Hospital Charge Code |
761T2121
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$49.50 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna Commercial |
$127.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.70
|
| Rate for Payer: Cash Price |
$82.50
|
| Rate for Payer: Cigna Commercial |
$136.95
|
| Rate for Payer: First Health Commercial |
$156.75
|
| Rate for Payer: Humana Commercial |
$140.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$145.20
|
| Rate for Payer: Ohio Health Group HMO |
$123.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.85
|
| Rate for Payer: PHCS Commercial |
$158.40
|
| Rate for Payer: United Healthcare All Payer |
$145.20
|
|
|
DILTIAZEM 50MG/10ML VIAL
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 641601401
|
| Hospital Charge Code |
25003022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.97 |
| Max. Negotiated Rate |
$76.70 |
| Rate for Payer: Aetna Commercial |
$61.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.32
|
| Rate for Payer: Cash Price |
$39.95
|
| Rate for Payer: Cigna Commercial |
$66.32
|
| Rate for Payer: First Health Commercial |
$75.91
|
| Rate for Payer: Humana Commercial |
$67.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.31
|
| Rate for Payer: Ohio Health Group HMO |
$59.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.13
|
| Rate for Payer: PHCS Commercial |
$76.70
|
| Rate for Payer: United Healthcare All Payer |
$70.31
|
|
|
DILTIAZEM 50MG/10ML VIAL
|
Facility
|
OP
|
$79.90
|
|
|
Service Code
|
NDC 641601401
|
| Hospital Charge Code |
25003022
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.97 |
| Max. Negotiated Rate |
$76.70 |
| Rate for Payer: Aetna Commercial |
$61.52
|
| Rate for Payer: Anthem Medicaid |
$27.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.32
|
| Rate for Payer: Cash Price |
$39.95
|
| Rate for Payer: Cigna Commercial |
$66.32
|
| Rate for Payer: First Health Commercial |
$75.91
|
| Rate for Payer: Humana Commercial |
$67.92
|
| Rate for Payer: Humana KY Medicaid |
$27.48
|
| Rate for Payer: Kentucky WC Medicaid |
$27.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.31
|
| Rate for Payer: Ohio Health Group HMO |
$59.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$63.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.13
|
| Rate for Payer: PHCS Commercial |
$76.70
|
| Rate for Payer: United Healthcare All Payer |
$70.31
|
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
IP
|
$5,352.50
|
|
|
Service Code
|
HCPCS 53605
|
| Hospital Charge Code |
76102118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,605.75 |
| Max. Negotiated Rate |
$5,138.40 |
| Rate for Payer: Aetna Commercial |
$4,121.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,174.95
|
| Rate for Payer: Cash Price |
$2,676.25
|
| Rate for Payer: Cigna Commercial |
$4,442.57
|
| Rate for Payer: First Health Commercial |
$5,084.88
|
| Rate for Payer: Humana Commercial |
$4,549.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,389.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,950.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,605.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,710.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,014.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,282.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,656.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,693.22
|
| Rate for Payer: PHCS Commercial |
$5,138.40
|
| Rate for Payer: United Healthcare All Payer |
$4,710.20
|
|
|
DILURETHSTRIX/VES NCK DIL MALE
|
Facility
|
OP
|
$5,087.50
|
|
|
Service Code
|
HCPCS 53605
|
| Hospital Charge Code |
761T2118
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,749.59 |
| Max. Negotiated Rate |
$4,884.00 |
| Rate for Payer: Aetna Commercial |
$3,917.38
|
| Rate for Payer: Anthem Medicaid |
$1,749.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,186.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,968.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,461.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,302.15
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cash Price |
$2,543.75
|
| Rate for Payer: Cigna Commercial |
$4,222.62
|
| Rate for Payer: First Health Commercial |
$4,833.12
|
| Rate for Payer: Humana Commercial |
$4,324.38
|
| Rate for Payer: Humana KY Medicaid |
$1,749.59
|
| Rate for Payer: Humana Medicare Advantage |
$3,186.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,767.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,171.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,754.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,824.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,784.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,477.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,815.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,070.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,426.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,510.38
|
| Rate for Payer: PHCS Commercial |
$4,884.00
|
| Rate for Payer: United Healthcare All Payer |
$4,477.00
|
|
