|
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 |
$29.32 |
| 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 |
$78.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.43
|
| 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 |
$29.32 |
| 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 |
$78.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67.43
|
| Rate for Payer: PHCS Commercial |
$93.81
|
| Rate for Payer: United Healthcare All Payer |
$85.99
|
|
|
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 |
$2.80 |
| 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 |
$7.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.44
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
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 |
$2.80 |
| 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 |
$7.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.44
|
| Rate for Payer: PHCS Commercial |
$8.96
|
| Rate for Payer: United Healthcare All Payer |
$8.21
|
|
|
ALCAINE/PROPARAC 0.5% BOTTLE
|
Facility
|
IP
|
$186.10
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
25000179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$178.66 |
| Rate for Payer: Aetna Commercial |
$143.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.16
|
| Rate for Payer: Cash Price |
$93.05
|
| Rate for Payer: Cigna Commercial |
$154.46
|
| Rate for Payer: First Health Commercial |
$176.79
|
| Rate for Payer: Humana Commercial |
$158.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.77
|
| Rate for Payer: Ohio Health Group HMO |
$139.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.41
|
| Rate for Payer: PHCS Commercial |
$178.66
|
| Rate for Payer: United Healthcare All Payer |
$163.77
|
|
|
ALCAINE/PROPARAC 0.5% BOTTLE
|
Facility
|
OP
|
$186.10
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
25000179
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.83 |
| Max. Negotiated Rate |
$178.66 |
| Rate for Payer: Aetna Commercial |
$143.30
|
| Rate for Payer: Anthem Medicaid |
$64.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.16
|
| Rate for Payer: Cash Price |
$93.05
|
| Rate for Payer: Cigna Commercial |
$154.46
|
| Rate for Payer: First Health Commercial |
$176.79
|
| Rate for Payer: Humana Commercial |
$158.19
|
| Rate for Payer: Humana KY Medicaid |
$64.00
|
| Rate for Payer: Kentucky WC Medicaid |
$64.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.77
|
| Rate for Payer: Ohio Health Group HMO |
$139.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.41
|
| Rate for Payer: PHCS Commercial |
$178.66
|
| Rate for Payer: United Healthcare All Payer |
$163.77
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS H0049
|
| Hospital Charge Code |
51000146
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.00 |
| 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 |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
ALCOHOL AND/OR DRUG SCREENING
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS H0049
|
| Hospital Charge Code |
51000146
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.00 |
| 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 |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| 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 |
$70.00 |
| Rate for Payer: Anthem Medicaid |
$24.06
|
| 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/DRUG BRIEF INT EA15MIN
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS H0050
|
| Hospital Charge Code |
51000147
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.00 |
| 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 |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.40
|
| 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 |
$48.00 |
| 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 |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.40
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
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 |
$112.00 |
| 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/SUBS INTERV 15-30MN
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
51000140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.00 |
| 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 |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| 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 |
$30.06 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$46.81
|
| Rate for Payer: Ambetter Exchange |
$30.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$30.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$30.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.07
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$30.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.06
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$39.08
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$30.06
|
|
|
ALCOHOL/SUBS INTERV 15-30MN
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS G0396
|
| Hospital Charge Code |
51000140
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$27.53 |
| 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 |
$27.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$38.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$37.17
|
| 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 |
$27.53
|
| 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 |
$33.04
|
| 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 |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
ALCOHOL/SUBS INTERV >30 MIN
|
Facility
|
IP
|
$160.00
|
|
|
Service Code
|
HCPCS G0397
|
| Hospital Charge Code |
51000141
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$48.00 |
| 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 |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.40
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
ALCOHOL/SUBS INTERV >30 MIN
|
Professional
|
Both
|
$160.00
|
|
|
Service Code
|
HCPCS G0397
|
| Hospital Charge Code |
51000141
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$56.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$93.78
|
| Rate for Payer: Ambetter Exchange |
$58.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$58.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$58.53
|
| Rate for Payer: CareSource Just4Me Medicare |
$70.24
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.51
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$58.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.53
|
| Rate for Payer: Multiplan PHCS |
$96.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$76.09
|
| Rate for Payer: UHCCP Medicaid |
$56.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$58.53
|
|
|
ALCOHOL/SUBS INTERV >30 MIN
|
Facility
|
OP
|
$160.00
|
|
|
Service Code
|
HCPCS G0397
|
| Hospital Charge Code |
51000141
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$55.02 |
| Max. Negotiated Rate |
$207.84 |
| Rate for Payer: Aetna Commercial |
$123.20
|
| Rate for Payer: Anthem Medicaid |
$55.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$148.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$207.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$200.42
|
| Rate for Payer: Cash Price |
$80.00
|
| 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: Humana Medicare Advantage |
$148.46
|
| 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 |
$178.15
|
| 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 |
$128.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$139.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$110.40
|
| Rate for Payer: PHCS Commercial |
$153.60
|
| Rate for Payer: United Healthcare All Payer |
$140.80
|
|
|
ALDACTONE(SPIRONOLAC 25MG/1TAB
|
Facility
|
OP
|
$4.38
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
25000180
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
ALDACTONE(SPIRONOLAC 25MG/1TAB
|
Facility
|
IP
|
$4.38
|
|
|
Service Code
|
NDC 51079010320
|
| Hospital Charge Code |
25000180
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$4.20 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.16
|
| Rate for Payer: Humana Commercial |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.85
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.02
|
| Rate for Payer: PHCS Commercial |
$4.20
|
| Rate for Payer: United Healthcare All Payer |
$3.85
|
|
|
ALDOMET (METHYLDOPA 250MG/1TAB
|
Facility
|
OP
|
$4.39
|
|
|
Service Code
|
NDC 378061101
|
| Hospital Charge Code |
25000182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem Medicaid |
$1.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Humana KY Medicaid |
$1.51
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
ALDOMET (METHYLDOPA 250MG/1TAB
|
Facility
|
IP
|
$4.39
|
|
|
Service Code
|
NDC 378061101
|
| Hospital Charge Code |
25000182
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.42
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cigna Commercial |
$3.64
|
| Rate for Payer: First Health Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.86
|
| Rate for Payer: Ohio Health Group HMO |
$3.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.03
|
| Rate for Payer: PHCS Commercial |
$4.21
|
| Rate for Payer: United Healthcare All Payer |
$3.86
|
|
|
ALDOMET (METHYLDOPA 500MG/1TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 51079020120
|
| Hospital Charge Code |
25000183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
ALDOMET (METHYLDOPA 500MG/1TAB
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 51079020120
|
| Hospital Charge Code |
25000183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
AL I CATH 6F 100CM
|
Facility
|
IP
|
$163.69
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.11 |
| Max. Negotiated Rate |
$157.14 |
| Rate for Payer: Aetna Commercial |
$126.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Cash Price |
$81.84
|
| Rate for Payer: Cigna Commercial |
$135.86
|
| Rate for Payer: First Health Commercial |
$155.51
|
| Rate for Payer: Humana Commercial |
$139.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.05
|
| Rate for Payer: Ohio Health Group HMO |
$122.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.95
|
| Rate for Payer: PHCS Commercial |
$157.14
|
| Rate for Payer: United Healthcare All Payer |
$144.05
|
|
