|
ECMO/ECLS INITIATION VENOUS(P
|
Professional
|
Both
|
$520.00
|
|
|
Service Code
|
HCPCS 33946
|
| Hospital Charge Code |
761P1320
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.00 |
| Max. Negotiated Rate |
$569.72 |
| Rate for Payer: Anthem Medicaid |
$252.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$520.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cash Price |
$260.00
|
| Rate for Payer: Cigna Commercial |
$569.72
|
| Rate for Payer: Humana Medicaid |
$252.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$416.35
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.86
|
| Rate for Payer: Molina Healthcare Passport |
$252.80
|
| Rate for Payer: Multiplan PHCS |
$312.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$364.00
|
| Rate for Payer: UHCCP Medicaid |
$182.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$255.33
|
|
|
ECMO/ECLS INSJ CTR CANNULA
|
Facility
|
IP
|
$2,180.00
|
|
|
Service Code
|
HCPCS 33956
|
| Hospital Charge Code |
76101323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$283.40 |
| Max. Negotiated Rate |
$2,092.80 |
| Rate for Payer: Aetna Commercial |
$1,678.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,700.40
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,809.40
|
| Rate for Payer: First Health Commercial |
$2,071.00
|
| Rate for Payer: Humana Commercial |
$1,853.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,787.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$654.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,918.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,635.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$283.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$675.80
|
| Rate for Payer: PHCS Commercial |
$2,092.80
|
| Rate for Payer: United Healthcare All Payer |
$1,918.40
|
|
|
ECMO/ECLS INSJ CTR CANNULA
|
Professional
|
Both
|
$2,180.00
|
|
|
Service Code
|
HCPCS 33956
|
| Hospital Charge Code |
76101323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$688.02 |
| Max. Negotiated Rate |
$2,180.00 |
| Rate for Payer: Anthem Medicaid |
$688.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,180.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,557.15
|
| Rate for Payer: Humana Medicaid |
$688.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,139.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.78
|
| Rate for Payer: Molina Healthcare Passport |
$688.02
|
| Rate for Payer: Multiplan PHCS |
$1,308.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,526.00
|
| Rate for Payer: UHCCP Medicaid |
$763.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.90
|
|
|
ECMO/ECLS INSJ CTR CANNULA
|
Facility
|
OP
|
$2,180.00
|
|
|
Service Code
|
HCPCS 33956
|
| Hospital Charge Code |
76101323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$283.40 |
| Max. Negotiated Rate |
$2,092.80 |
| Rate for Payer: Aetna Commercial |
$1,678.60
|
| Rate for Payer: Anthem Medicaid |
$749.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,700.40
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,809.40
|
| Rate for Payer: First Health Commercial |
$2,071.00
|
| Rate for Payer: Humana Commercial |
$1,853.00
|
| Rate for Payer: Humana KY Medicaid |
$749.70
|
| Rate for Payer: Kentucky WC Medicaid |
$757.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,787.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$654.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$764.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,918.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,635.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$436.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$283.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$675.80
|
| Rate for Payer: PHCS Commercial |
$2,092.80
|
| Rate for Payer: United Healthcare All Payer |
$1,918.40
|
|
|
ECMO/ECLS INSJ CTR CANNULA(P
|
Professional
|
Both
|
$2,180.00
|
|
|
Service Code
|
HCPCS 33956
|
| Hospital Charge Code |
761P1323
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$688.02 |
| Max. Negotiated Rate |
$2,180.00 |
| Rate for Payer: Anthem Medicaid |
$688.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,180.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cigna Commercial |
$1,557.15
|
| Rate for Payer: Humana Medicaid |
$688.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,139.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$701.78
|
| Rate for Payer: Molina Healthcare Passport |
$688.02
|
| Rate for Payer: Multiplan PHCS |
$1,308.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,526.00
|
| Rate for Payer: UHCCP Medicaid |
$763.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.90
|
|
|
ECMO/ECLS INSJ PRPH CANNULA
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
76101322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$157.30 |
| Max. Negotiated Rate |
$1,161.60 |
| Rate for Payer: Aetna Commercial |
$931.70
|
| Rate for Payer: Anthem Medicaid |
$416.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$943.80
|
| Rate for Payer: Cash Price |
$605.00
|
| Rate for Payer: Cigna Commercial |
$1,004.30
|
| Rate for Payer: First Health Commercial |
$1,149.50
|
| Rate for Payer: Humana Commercial |
$1,028.50
|
| Rate for Payer: Humana KY Medicaid |
$416.12
|
| Rate for Payer: Kentucky WC Medicaid |
$420.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$992.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$892.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$363.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$424.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,064.80
|
| Rate for Payer: Ohio Health Group HMO |
$907.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$375.10
|
| Rate for Payer: PHCS Commercial |
$1,161.60
|
| Rate for Payer: United Healthcare All Payer |
$1,064.80
|
|
|
ECMO/ECLS INSJ PRPH CANNULA
|
Professional
|
Both
|
$1,210.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
76101322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$351.07 |
| Max. Negotiated Rate |
$1,210.00 |
| Rate for Payer: Anthem Medicaid |
$351.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,210.00
|
| Rate for Payer: Cash Price |
$605.00
|
| Rate for Payer: Cash Price |
$605.00
|
| Rate for Payer: Cigna Commercial |
$794.27
|
| Rate for Payer: Humana Medicaid |
$351.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$581.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$358.09
|
| Rate for Payer: Molina Healthcare Passport |
$351.07
|
| Rate for Payer: Multiplan PHCS |
$726.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$847.00
|
| Rate for Payer: UHCCP Medicaid |
$423.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$354.58
|
|
|
ECMO/ECLS INSJ PRPH CANNULA
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
76101322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$157.30 |
| Max. Negotiated Rate |
$1,161.60 |
| Rate for Payer: Aetna Commercial |
$931.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$943.80
|
| Rate for Payer: Cash Price |
$605.00
|
| Rate for Payer: Cigna Commercial |
$1,004.30
|
| Rate for Payer: First Health Commercial |
$1,149.50
|
| Rate for Payer: Humana Commercial |
$1,028.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$992.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$892.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$363.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,064.80
|
| Rate for Payer: Ohio Health Group HMO |
$907.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$375.10
|
| Rate for Payer: PHCS Commercial |
$1,161.60
|
| Rate for Payer: United Healthcare All Payer |
$1,064.80
|
|
|
ECMO/ECLS INSJ PRPH CANNULA(P
|
Professional
|
Both
|
$1,210.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
761P1322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$351.07 |
| Max. Negotiated Rate |
$1,210.00 |
| Rate for Payer: Anthem Medicaid |
$351.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,210.00
|
| Rate for Payer: Cash Price |
$605.00
|
| Rate for Payer: Cash Price |
$605.00
|
| Rate for Payer: Cigna Commercial |
$794.27
|
| Rate for Payer: Humana Medicaid |
$351.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$581.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$358.09
|
| Rate for Payer: Molina Healthcare Passport |
$351.07
|
| Rate for Payer: Multiplan PHCS |
$726.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$847.00
|
| Rate for Payer: UHCCP Medicaid |
$423.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$354.58
|
|
|
ECMO/ECLS RMVL PRPH CANNULA
|
Professional
|
Both
|
$315.00
|
|
|
Service Code
|
HCPCS 33984
|
| Hospital Charge Code |
76102762
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$110.25 |
| Max. Negotiated Rate |
$528.41 |
| Rate for Payer: Anthem Medicaid |
$233.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$315.00
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna Commercial |
$528.41
|
| Rate for Payer: Humana Medicaid |
$233.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$386.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.32
|
| Rate for Payer: Molina Healthcare Passport |
$233.65
|
| Rate for Payer: Multiplan PHCS |
$189.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$220.50
|
| Rate for Payer: UHCCP Medicaid |
$110.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$235.99
|
|
|
ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITH MAJOR O.R. PROCEDURES
|
Facility
|
IP
|
$249,409.26
|
|
|
Service Code
|
MSDRG 003
|
| Min. Negotiated Rate |
$169,242.00 |
| Max. Negotiated Rate |
$249,409.26 |
| Rate for Payer: Anthem Medicaid |
$169,242.00
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$178,149.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$249,409.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$240,501.78
|
| Rate for Payer: Humana KY Medicaid |
$169,242.00
|
| Rate for Payer: Humana Medicare Advantage |
$178,149.47
|
| Rate for Payer: Kentucky WC Medicaid |
$170,934.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$213,779.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$172,626.84
|
|
|
ECONAZOLE NIRATE 1% CREAM 15GM
|
Facility
|
IP
|
$11.74
|
|
|
Service Code
|
NDC 45802046635
|
| Hospital Charge Code |
25003035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna Commercial |
$9.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.16
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.15
|
| Rate for Payer: Humana Commercial |
$9.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.33
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.27
|
| Rate for Payer: United Healthcare All Payer |
$10.33
|
|
|
ECONAZOLE NIRATE 1% CREAM 15GM
|
Facility
|
OP
|
$11.74
|
|
|
Service Code
|
NDC 45802046635
|
| Hospital Charge Code |
25003035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$11.27 |
| Rate for Payer: Aetna Commercial |
$9.04
|
| Rate for Payer: Anthem Medicaid |
$4.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.16
|
| Rate for Payer: Cash Price |
$5.87
|
| Rate for Payer: Cigna Commercial |
$9.74
|
| Rate for Payer: First Health Commercial |
$11.15
|
| Rate for Payer: Humana Commercial |
$9.98
|
| Rate for Payer: Humana KY Medicaid |
$4.04
|
| Rate for Payer: Kentucky WC Medicaid |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.33
|
| Rate for Payer: Ohio Health Group HMO |
$8.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.64
|
| Rate for Payer: PHCS Commercial |
$11.27
|
| Rate for Payer: United Healthcare All Payer |
$10.33
|
|
|
ECTOPIC PREG W/O S/O
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59121
|
| Hospital Charge Code |
72000008
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
ECTOPIC PREG W/O S/O
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59121
|
| Hospital Charge Code |
72000008
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$375.41 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,298.34
|
| Rate for Payer: Anthem Medicaid |
$375.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,195.07
|
| Rate for Payer: Healthspan PPO |
$942.36
|
| Rate for Payer: Humana Medicaid |
$375.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,057.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$382.92
|
| Rate for Payer: Molina Healthcare Passport |
$375.41
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.16
|
|
|
ECTOPIC PREG W/O S/O
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59121
|
| Hospital Charge Code |
72000008
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
ECTOPIC PREG W/O S/O(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59121
|
| Hospital Charge Code |
720P0008
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$375.41 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,298.34
|
| Rate for Payer: Anthem Medicaid |
$375.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,195.07
|
| Rate for Payer: Healthspan PPO |
$942.36
|
| Rate for Payer: Humana Medicaid |
$375.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,057.81
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$382.92
|
| Rate for Payer: Molina Healthcare Passport |
$375.41
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.16
|
|
|
ECTOPIC PREG W/ S/O
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59120
|
| Hospital Charge Code |
72000007
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem Medicaid |
$619.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Humana KY Medicaid |
$619.02
|
| Rate for Payer: Kentucky WC Medicaid |
$625.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
ECTOPIC PREG W/ S/O
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59120
|
| Hospital Charge Code |
72000007
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$455.90 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,290.71
|
| Rate for Payer: Anthem Medicaid |
$455.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,185.07
|
| Rate for Payer: Healthspan PPO |
$936.81
|
| Rate for Payer: Humana Medicaid |
$455.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,056.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$465.02
|
| Rate for Payer: Molina Healthcare Passport |
$455.90
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$460.46
|
|
|
ECTOPIC PREG W/ S/O
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59120
|
| Hospital Charge Code |
72000007
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,728.00 |
| Rate for Payer: Aetna Commercial |
$1,386.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,404.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,494.00
|
| Rate for Payer: First Health Commercial |
$1,710.00
|
| Rate for Payer: Humana Commercial |
$1,530.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,476.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,328.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,584.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,350.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
ECTOPIC PREG W/ S/O(P
|
Professional
|
Both
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59120
|
| Hospital Charge Code |
720P0007
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$455.90 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,290.71
|
| Rate for Payer: Anthem Medicaid |
$455.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,800.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cash Price |
$900.00
|
| Rate for Payer: Cigna Commercial |
$1,185.07
|
| Rate for Payer: Healthspan PPO |
$936.81
|
| Rate for Payer: Humana Medicaid |
$455.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,056.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$465.02
|
| Rate for Payer: Molina Healthcare Passport |
$455.90
|
| Rate for Payer: Multiplan PHCS |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,260.00
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$460.46
|
|
|
EDARBI 40 MG TABLET
|
Facility
|
IP
|
$24.92
|
|
|
Service Code
|
NDC 60631004030
|
| Hospital Charge Code |
25000592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$19.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.44
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cigna Commercial |
$20.68
|
| Rate for Payer: First Health Commercial |
$23.67
|
| Rate for Payer: Humana Commercial |
$21.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.93
|
| Rate for Payer: Ohio Health Group HMO |
$18.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.73
|
| Rate for Payer: PHCS Commercial |
$23.92
|
| Rate for Payer: United Healthcare All Payer |
$21.93
|
|
|
EDARBI 40 MG TABLET
|
Facility
|
OP
|
$24.92
|
|
|
Service Code
|
NDC 60631004030
|
| Hospital Charge Code |
25000592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$23.92 |
| Rate for Payer: Aetna Commercial |
$19.19
|
| Rate for Payer: Anthem Medicaid |
$8.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.44
|
| Rate for Payer: Cash Price |
$12.46
|
| Rate for Payer: Cigna Commercial |
$20.68
|
| Rate for Payer: First Health Commercial |
$23.67
|
| Rate for Payer: Humana Commercial |
$21.18
|
| Rate for Payer: Humana KY Medicaid |
$8.57
|
| Rate for Payer: Kentucky WC Medicaid |
$8.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$21.93
|
| Rate for Payer: Ohio Health Group HMO |
$18.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.73
|
| Rate for Payer: PHCS Commercial |
$23.92
|
| Rate for Payer: United Healthcare All Payer |
$21.93
|
|
|
EDARBI 80 MG TABLET
|
Facility
|
OP
|
$25.61
|
|
|
Service Code
|
NDC 60631008030
|
| Hospital Charge Code |
25000593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$24.59 |
| Rate for Payer: Aetna Commercial |
$19.72
|
| Rate for Payer: Anthem Medicaid |
$8.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.98
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cigna Commercial |
$21.26
|
| Rate for Payer: First Health Commercial |
$24.33
|
| Rate for Payer: Humana Commercial |
$21.77
|
| Rate for Payer: Humana KY Medicaid |
$8.81
|
| Rate for Payer: Kentucky WC Medicaid |
$8.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.54
|
| Rate for Payer: Ohio Health Group HMO |
$19.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.94
|
| Rate for Payer: PHCS Commercial |
$24.59
|
| Rate for Payer: United Healthcare All Payer |
$22.54
|
|
|
EDARBI 80 MG TABLET
|
Facility
|
IP
|
$25.61
|
|
|
Service Code
|
NDC 60631008030
|
| Hospital Charge Code |
25000593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$24.59 |
| Rate for Payer: Aetna Commercial |
$19.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.98
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cigna Commercial |
$21.26
|
| Rate for Payer: First Health Commercial |
$24.33
|
| Rate for Payer: Humana Commercial |
$21.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.54
|
| Rate for Payer: Ohio Health Group HMO |
$19.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.94
|
| Rate for Payer: PHCS Commercial |
$24.59
|
| Rate for Payer: United Healthcare All Payer |
$22.54
|
|
