|
ALBUTEROL 2.5MG/0.5ML SOLN
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
NDC 487990130
|
| Hospital Charge Code |
25000176
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.46
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
ALBUTEROL HFA 18 GM
|
Facility
|
IP
|
$292.02
|
|
|
Service Code
|
NDC 173068220
|
| Hospital Charge Code |
25003964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$280.34 |
| Rate for Payer: Aetna Commercial |
$224.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$227.78
|
| Rate for Payer: Cash Price |
$146.01
|
| Rate for Payer: Cigna Commercial |
$242.38
|
| Rate for Payer: First Health Commercial |
$277.42
|
| Rate for Payer: Humana Commercial |
$248.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.98
|
| Rate for Payer: Ohio Health Group HMO |
$219.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.53
|
| Rate for Payer: PHCS Commercial |
$280.34
|
| Rate for Payer: United Healthcare All Payer |
$256.98
|
|
|
ALBUTEROL HFA 18 GM
|
Facility
|
OP
|
$292.02
|
|
|
Service Code
|
NDC 173068220
|
| Hospital Charge Code |
25003964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.96 |
| Max. Negotiated Rate |
$280.34 |
| Rate for Payer: Aetna Commercial |
$224.86
|
| Rate for Payer: Anthem Medicaid |
$100.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$227.78
|
| Rate for Payer: Cash Price |
$146.01
|
| Rate for Payer: Cigna Commercial |
$242.38
|
| Rate for Payer: First Health Commercial |
$277.42
|
| Rate for Payer: Humana Commercial |
$248.22
|
| Rate for Payer: Humana KY Medicaid |
$100.43
|
| Rate for Payer: Kentucky WC Medicaid |
$101.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$239.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$215.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$87.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$102.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$256.98
|
| Rate for Payer: Ohio Health Group HMO |
$219.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.53
|
| Rate for Payer: PHCS Commercial |
$280.34
|
| Rate for Payer: United Healthcare All Payer |
$256.98
|
|
|
ALBUTEROL HFA 200 PUFF/8.5 GM
|
Professional
|
Both
|
$176.72
|
|
| Hospital Charge Code |
25000178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.85 |
| Max. Negotiated Rate |
$176.72 |
| Rate for Payer: Buckeye Medicare Advantage |
$176.72
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Multiplan PHCS |
$106.03
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$123.70
|
| Rate for Payer: UHCCP Medicaid |
$61.85
|
|
|
ALBUTEROL HFA 200 PUFF/8.5 GM
|
Facility
|
IP
|
$186.98
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
25000178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna Commercial |
$143.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.84
|
| Rate for Payer: Cash Price |
$93.49
|
| Rate for Payer: Cigna Commercial |
$155.19
|
| Rate for Payer: First Health Commercial |
$177.63
|
| Rate for Payer: Humana Commercial |
$158.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.54
|
| Rate for Payer: Ohio Health Group HMO |
$140.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.96
|
| Rate for Payer: PHCS Commercial |
$179.50
|
| Rate for Payer: United Healthcare All Payer |
$164.54
|
|
|
ALBUTEROL HFA 200 PUFF/8.5 GM
|
Facility
|
OP
|
$186.98
|
|
|
Service Code
|
HCPCS J3535
|
| Hospital Charge Code |
25000178
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.31 |
| Max. Negotiated Rate |
$179.50 |
| Rate for Payer: Aetna Commercial |
$143.97
|
| Rate for Payer: Anthem Medicaid |
$64.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.84
|
| Rate for Payer: Cash Price |
$93.49
|
| Rate for Payer: Cigna Commercial |
$155.19
|
| Rate for Payer: First Health Commercial |
$177.63
|
| Rate for Payer: Humana Commercial |
$158.93
|
| Rate for Payer: Humana KY Medicaid |
$64.30
|
| Rate for Payer: Kentucky WC Medicaid |
$64.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$153.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.54
|
| Rate for Payer: Ohio Health Group HMO |
$140.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.96
|
| Rate for Payer: PHCS Commercial |
$179.50
|
| Rate for Payer: United Healthcare All Payer |
$164.54
|
|
|
ALBUTEROL HFA 60 PUFF/8 GM INH
|
Facility
|
OP
|
$97.72
|
|
|
Service Code
|
NDC 173068224
|
| Hospital Charge Code |
25001659
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$93.81 |
| Rate for Payer: Aetna Commercial |
$75.24
|
| Rate for Payer: Anthem Medicaid |
$33.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.22
|
| Rate for Payer: Cash Price |
$48.86
|
| Rate for Payer: Cigna Commercial |
$81.11
|
| Rate for Payer: First Health Commercial |
$92.83
|
| Rate for Payer: Humana Commercial |
$83.06
|
| Rate for Payer: Humana KY Medicaid |
$33.61
|
| Rate for Payer: Kentucky WC Medicaid |
$33.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.99
|
| Rate for Payer: Ohio Health Group HMO |
$73.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.29
|
| Rate for Payer: PHCS Commercial |
$93.81
|
| Rate for Payer: United Healthcare All Payer |
$85.99
|
|
|
ALBUTEROL HFA 60 PUFF/8 GM INH
|
Facility
|
IP
|
$97.72
|
|
|
Service Code
|
NDC 173068224
|
| Hospital Charge Code |
25001659
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$93.81 |
| Rate for Payer: Aetna Commercial |
$75.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.22
|
| Rate for Payer: Cash Price |
$48.86
|
| Rate for Payer: Cigna Commercial |
$81.11
|
| Rate for Payer: First Health Commercial |
$92.83
|
| Rate for Payer: Humana Commercial |
$83.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$85.99
|
| Rate for Payer: Ohio Health Group HMO |
$73.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.29
|
| Rate for Payer: PHCS Commercial |
$93.81
|
| Rate for Payer: United Healthcare All Payer |
$85.99
|
|
|
ALBUTEROL SULF 1.25MG/3ML NEB
|
Facility
|
OP
|
$9.33
|
|
|
Service Code
|
NDC 487990425
|
| Hospital Charge Code |
25002812
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem Medicaid |
$3.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.86
|
| Rate for Payer: Humana Commercial |
$7.93
|
| Rate for Payer: Humana KY Medicaid |
$3.21
|
| Rate for Payer: Kentucky WC Medicaid |
$3.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.21
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
ALBUTEROL SULF 1.25MG/3ML NEB
|
Facility
|
IP
|
$9.33
|
|
|
Service Code
|
NDC 487990425
|
| Hospital Charge Code |
25002812
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$8.96 |
| Rate for Payer: Aetna Commercial |
$7.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.28
|
| Rate for Payer: Cash Price |
$4.66
|
| Rate for Payer: Cigna Commercial |
$7.74
|
| Rate for Payer: First Health Commercial |
$8.86
|
| Rate for Payer: Humana Commercial |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.21
|
| Rate for Payer: Ohio Health Group HMO |
$7.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.89
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
ALCAINE/PROPARAC 0.5% PER DROP
|
Facility
|
IP
|
$4.32
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
25000179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
ALCAINE/PROPARAC 0.5% PER DROP
|
Facility
|
OP
|
$4.32
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
25000179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.15 |
| Rate for Payer: Aetna Commercial |
$3.33
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Cash Price |
$2.16
|
| Rate for Payer: Cigna Commercial |
$3.59
|
| Rate for Payer: First Health Commercial |
$4.10
|
| Rate for Payer: Humana Commercial |
$3.67
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.80
|
| Rate for Payer: Ohio Health Group HMO |
$3.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.15
|
| Rate for Payer: United Healthcare All Payer |
$3.80
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS H0049
|
| Hospital Charge Code |
51000146
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS H0049
|
| Hospital Charge Code |
51000146
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.06 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Anthem Medicaid |
$24.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Humana Medicaid |
$24.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$24.54
|
| Rate for Payer: Molina Healthcare Passport |
$24.06
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$24.30
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS H0049
|
| Hospital Charge Code |
51000146
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA
|
Facility
|
IP
|
$6,720.60
|
|
|
Service Code
|
MSDRG 894
|
| Min. Negotiated Rate |
$4,560.41 |
| Max. Negotiated Rate |
$6,720.60 |
| Rate for Payer: Anthem Medicaid |
$4,560.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,800.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,720.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,480.58
|
| Rate for Payer: Humana KY Medicaid |
$4,560.41
|
| Rate for Payer: Humana Medicare Advantage |
$4,800.43
|
| Rate for Payer: Kentucky WC Medicaid |
$4,606.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,760.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,651.62
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC
|
Facility
|
IP
|
$20,800.58
|
|
|
Service Code
|
MSDRG 896
|
| Min. Negotiated Rate |
$14,114.68 |
| Max. Negotiated Rate |
$20,800.58 |
| Rate for Payer: Anthem Medicaid |
$14,114.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14,857.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20,800.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,057.71
|
| Rate for Payer: Humana KY Medicaid |
$14,114.68
|
| Rate for Payer: Humana Medicare Advantage |
$14,857.56
|
| Rate for Payer: Kentucky WC Medicaid |
$14,255.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17,829.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,396.98
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC
|
Facility
|
IP
|
$10,008.99
|
|
|
Service Code
|
MSDRG 897
|
| Min. Negotiated Rate |
$6,791.82 |
| Max. Negotiated Rate |
$10,008.99 |
| Rate for Payer: Anthem Medicaid |
$6,791.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,149.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,008.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,651.53
|
| Rate for Payer: Humana KY Medicaid |
$6,791.82
|
| Rate for Payer: Humana Medicare Advantage |
$7,149.28
|
| Rate for Payer: Kentucky WC Medicaid |
$6,859.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,579.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,927.65
|
|
|
ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY
|
Facility
|
IP
|
$18,820.07
|
|
|
Service Code
|
MSDRG 895
|
| Min. Negotiated Rate |
$12,770.76 |
| Max. Negotiated Rate |
$18,820.07 |
| Rate for Payer: Anthem Medicaid |
$12,770.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,442.91
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18,820.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,147.93
|
| Rate for Payer: Humana KY Medicaid |
$12,770.76
|
| Rate for Payer: Humana Medicare Advantage |
$13,442.91
|
| Rate for Payer: Kentucky WC Medicaid |
$12,898.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,131.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,026.18
|
|
|
ALCOHOL/DRUG BRIEF INT EA15MIN
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS H0050
|
| Hospital Charge Code |
51000147
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$160.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$160.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.00
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
|
|
ALCOHOL/DRUG BRIEF INT EA15MIN
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS H0050
|
| Hospital Charge Code |
51000147
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.60 |
| Rate for Payer: Aetna Commercial |
$123.20
|
| Rate for Payer: Anthem Medicaid |
$55.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.80
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: First Health Commercial |
$152.00
|
| Rate for Payer: Humana Commercial |
$136.00
|
| Rate for Payer: Humana KY Medicaid |
$55.02
|
| Rate for Payer: Kentucky WC Medicaid |
$55.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$56.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.80
|
| Rate for Payer: Ohio Health Group HMO |
$120.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.60
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
ALCOHOL/DRUG BRIEF INT EA15MIN
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS H0050
|
| Hospital Charge Code |
51000147
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.60 |
| Rate for Payer: Aetna Commercial |
$123.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.80
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna Commercial |
$132.80
|
| Rate for Payer: First Health Commercial |
$152.00
|
| Rate for Payer: Humana Commercial |
$136.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.80
|
| Rate for Payer: Ohio Health Group HMO |
$120.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.60
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
ALCOHOL/SUBS INTERV 15-30MN
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
51000140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
ALCOHOL/SUBS INTERV 15-30MN
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
51000140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$24.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$34.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$33.49
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Humana Medicare Advantage |
$24.81
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
ALCOHOL/SUBS INTERV 15-30MN
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
51000140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$46.81
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$36.36
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
|
