|
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 |
$654.00 |
| 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 |
$1,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,896.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,504.20
|
| Rate for Payer: PHCS Commercial |
$2,092.80
|
| Rate for Payer: United Healthcare All Payer |
$1,918.40
|
|
|
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 |
$654.00 |
| 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 |
$1,744.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,896.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,504.20
|
| 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 |
$1,557.15 |
| Rate for Payer: Ambetter Exchange |
$781.68
|
| Rate for Payer: Anthem Medicaid |
$688.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$781.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$781.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$938.02
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$781.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$781.68
|
| 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 |
$1,016.18
|
| Rate for Payer: UHCCP Medicaid |
$763.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$694.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$781.68
|
|
|
ECMO/ECLS INSJ PRPH CANNULA
|
Professional
|
Both
|
$156,460.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
76101322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$351.07 |
| Max. Negotiated Rate |
$93,876.00 |
| Rate for Payer: Ambetter Exchange |
$399.21
|
| Rate for Payer: Anthem Medicaid |
$351.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$399.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$399.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$479.05
|
| Rate for Payer: Cash Price |
$78,230.00
|
| Rate for Payer: Cash Price |
$78,230.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$399.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$358.09
|
| Rate for Payer: Molina Healthcare Passport |
$351.07
|
| Rate for Payer: Multiplan PHCS |
$93,876.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$518.97
|
| Rate for Payer: UHCCP Medicaid |
$54,761.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$354.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$399.21
|
|
|
ECMO/ECLS INSJ PRPH CANNULA
|
Facility
|
OP
|
$156,460.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
76101322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$46,938.00 |
| Max. Negotiated Rate |
$150,201.60 |
| Rate for Payer: Aetna Commercial |
$120,474.20
|
| Rate for Payer: Anthem Medicaid |
$53,806.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$122,038.80
|
| Rate for Payer: Cash Price |
$78,230.00
|
| Rate for Payer: Cigna Commercial |
$129,861.80
|
| Rate for Payer: First Health Commercial |
$148,637.00
|
| Rate for Payer: Humana Commercial |
$132,991.00
|
| Rate for Payer: Humana KY Medicaid |
$53,806.59
|
| Rate for Payer: Kentucky WC Medicaid |
$54,354.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$128,297.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115,467.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46,938.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$54,886.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$137,684.80
|
| Rate for Payer: Ohio Health Group HMO |
$117,345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125,168.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136,120.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107,957.40
|
| Rate for Payer: PHCS Commercial |
$150,201.60
|
| Rate for Payer: United Healthcare All Payer |
$137,684.80
|
|
|
ECMO/ECLS INSJ PRPH CANNULA
|
Facility
|
IP
|
$156,460.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
76101322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$46,938.00 |
| Max. Negotiated Rate |
$150,201.60 |
| Rate for Payer: Aetna Commercial |
$120,474.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$122,038.80
|
| Rate for Payer: Cash Price |
$78,230.00
|
| Rate for Payer: Cigna Commercial |
$129,861.80
|
| Rate for Payer: First Health Commercial |
$148,637.00
|
| Rate for Payer: Humana Commercial |
$132,991.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$128,297.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115,467.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46,938.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$137,684.80
|
| Rate for Payer: Ohio Health Group HMO |
$117,345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125,168.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$136,120.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107,957.40
|
| Rate for Payer: PHCS Commercial |
$150,201.60
|
| Rate for Payer: United Healthcare All Payer |
$137,684.80
|
|
|
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 |
$794.27 |
| Rate for Payer: Ambetter Exchange |
$399.21
|
| Rate for Payer: Anthem Medicaid |
$351.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$399.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$399.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$479.05
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$399.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$399.21
|
| 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 |
$518.97
|
| Rate for Payer: UHCCP Medicaid |
$423.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$354.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$399.21
|
|
|
ECMO/ECLS INSJ PRPH CANNULA(T
|
Facility
|
OP
|
$155,250.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
761T1322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$46,575.00 |
| Max. Negotiated Rate |
$149,040.00 |
| Rate for Payer: Aetna Commercial |
$119,542.50
|
| Rate for Payer: Anthem Medicaid |
$53,390.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121,095.00
|
| Rate for Payer: Cash Price |
$77,625.00
|
| Rate for Payer: Cigna Commercial |
$128,857.50
|
| Rate for Payer: First Health Commercial |
$147,487.50
|
| Rate for Payer: Humana Commercial |
$131,962.50
|
| Rate for Payer: Humana KY Medicaid |
$53,390.47
|
| Rate for Payer: Kentucky WC Medicaid |
$53,933.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127,305.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114,574.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46,575.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$54,461.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$136,620.00
|
| Rate for Payer: Ohio Health Group HMO |
$116,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135,067.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107,122.50
|
| Rate for Payer: PHCS Commercial |
$149,040.00
|
| Rate for Payer: United Healthcare All Payer |
$136,620.00
|
|
|
ECMO/ECLS INSJ PRPH CANNULA(T
|
Facility
|
IP
|
$155,250.00
|
|
|
Service Code
|
HCPCS 33952
|
| Hospital Charge Code |
761T1322
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$46,575.00 |
| Max. Negotiated Rate |
$149,040.00 |
| Rate for Payer: Aetna Commercial |
$119,542.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$121,095.00
|
| Rate for Payer: Cash Price |
$77,625.00
|
| Rate for Payer: Cigna Commercial |
$128,857.50
|
| Rate for Payer: First Health Commercial |
$147,487.50
|
| Rate for Payer: Humana Commercial |
$131,962.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127,305.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$114,574.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46,575.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$136,620.00
|
| Rate for Payer: Ohio Health Group HMO |
$116,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135,067.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107,122.50
|
| Rate for Payer: PHCS Commercial |
$149,040.00
|
| Rate for Payer: United Healthcare All Payer |
$136,620.00
|
|
|
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: Ambetter Exchange |
$266.31
|
| Rate for Payer: Anthem Medicaid |
$233.65
|
| Rate for Payer: Buckeye Individual/Medicaid |
$266.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$266.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$319.57
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$266.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.31
|
| 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 |
$346.20
|
| Rate for Payer: UHCCP Medicaid |
$110.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$235.99
|
| Rate for Payer: Wellcare Medicare Advantage |
$266.31
|
|
|
ECONAZOLE NIRATE 1% CREAM 15GM
|
Facility
|
OP
|
$11.74
|
|
|
Service Code
|
NDC 45802046635
|
| Hospital Charge Code |
25003035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| 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 |
$9.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.10
|
| Rate for Payer: PHCS Commercial |
$11.27
|
| Rate for Payer: United Healthcare All Payer |
$10.33
|
|
|
ECONAZOLE NIRATE 1% CREAM 15GM
|
Facility
|
IP
|
$11.74
|
|
|
Service Code
|
NDC 45802046635
|
| Hospital Charge Code |
25003035
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.52 |
| 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 |
$9.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.10
|
| Rate for Payer: PHCS Commercial |
$11.27
|
| Rate for Payer: United Healthcare All Payer |
$10.33
|
|
|
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 |
$540.00 |
| 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 |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| Rate for Payer: PHCS Commercial |
$1,728.00
|
| Rate for Payer: United Healthcare All Payer |
$1,584.00
|
|
|
ECTOPIC PREG W/O S/O
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 59121
|
| Hospital Charge Code |
72000008
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$540.00 |
| 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 |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| 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 |
$1,298.34 |
| Rate for Payer: Aetna Commercial |
$1,298.34
|
| Rate for Payer: Ambetter Exchange |
$779.47
|
| Rate for Payer: Anthem Medicaid |
$375.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$779.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$779.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$935.36
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$779.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$779.47
|
| 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 |
$1,013.31
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$779.47
|
|
|
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 |
$1,298.34 |
| Rate for Payer: Aetna Commercial |
$1,298.34
|
| Rate for Payer: Ambetter Exchange |
$779.47
|
| Rate for Payer: Anthem Medicaid |
$375.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$779.47
|
| Rate for Payer: Buckeye Medicare Advantage |
$779.47
|
| Rate for Payer: CareSource Just4Me Medicare |
$935.36
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$779.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$779.47
|
| 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 |
$1,013.31
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$379.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$779.47
|
|
|
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 |
$540.00 |
| 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 |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| 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 |
$1,290.71 |
| Rate for Payer: Aetna Commercial |
$1,290.71
|
| Rate for Payer: Ambetter Exchange |
$778.89
|
| Rate for Payer: Anthem Medicaid |
$455.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$778.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$778.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$934.67
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$778.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$778.89
|
| 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 |
$1,012.56
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$460.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$778.89
|
|
|
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 |
$540.00 |
| 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 |
$1,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,566.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,242.00
|
| 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 |
$1,290.71 |
| Rate for Payer: Aetna Commercial |
$1,290.71
|
| Rate for Payer: Ambetter Exchange |
$778.89
|
| Rate for Payer: Anthem Medicaid |
$455.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$778.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$778.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$934.67
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$778.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$778.89
|
| 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 |
$1,012.56
|
| Rate for Payer: UHCCP Medicaid |
$630.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$460.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$778.89
|
|
|
EDARBI 40 MG TABLET
|
Facility
|
IP
|
$25.64
|
|
|
Service Code
|
NDC 60631004030
|
| Hospital Charge Code |
25000592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna Commercial |
$19.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cigna Commercial |
$21.28
|
| Rate for Payer: First Health Commercial |
$24.36
|
| Rate for Payer: Humana Commercial |
$21.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.56
|
| Rate for Payer: Ohio Health Group HMO |
$19.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.69
|
| Rate for Payer: PHCS Commercial |
$24.61
|
| Rate for Payer: United Healthcare All Payer |
$22.56
|
|
|
EDARBI 40 MG TABLET
|
Facility
|
OP
|
$25.64
|
|
|
Service Code
|
NDC 60631004030
|
| Hospital Charge Code |
25000592
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.69 |
| Max. Negotiated Rate |
$24.61 |
| Rate for Payer: Aetna Commercial |
$19.74
|
| Rate for Payer: Anthem Medicaid |
$8.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.00
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cigna Commercial |
$21.28
|
| Rate for Payer: First Health Commercial |
$24.36
|
| Rate for Payer: Humana Commercial |
$21.79
|
| Rate for Payer: Humana KY Medicaid |
$8.82
|
| Rate for Payer: Kentucky WC Medicaid |
$8.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.56
|
| Rate for Payer: Ohio Health Group HMO |
$19.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.69
|
| Rate for Payer: PHCS Commercial |
$24.61
|
| Rate for Payer: United Healthcare All Payer |
$22.56
|
|
|
EDARBI 80 MG TABLET
|
Facility
|
IP
|
$26.39
|
|
|
Service Code
|
NDC 60631008030
|
| Hospital Charge Code |
25000593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$25.33 |
| Rate for Payer: Aetna Commercial |
$20.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.58
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$21.90
|
| Rate for Payer: First Health Commercial |
$25.07
|
| Rate for Payer: Humana Commercial |
$22.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.22
|
| Rate for Payer: Ohio Health Group HMO |
$19.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.21
|
| Rate for Payer: PHCS Commercial |
$25.33
|
| Rate for Payer: United Healthcare All Payer |
$23.22
|
|
|
EDARBI 80 MG TABLET
|
Facility
|
OP
|
$26.39
|
|
|
Service Code
|
NDC 60631008030
|
| Hospital Charge Code |
25000593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$25.33 |
| Rate for Payer: Aetna Commercial |
$20.32
|
| Rate for Payer: Anthem Medicaid |
$9.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.58
|
| Rate for Payer: Cash Price |
$13.20
|
| Rate for Payer: Cigna Commercial |
$21.90
|
| Rate for Payer: First Health Commercial |
$25.07
|
| Rate for Payer: Humana Commercial |
$22.43
|
| Rate for Payer: Humana KY Medicaid |
$9.08
|
| Rate for Payer: Kentucky WC Medicaid |
$9.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.22
|
| Rate for Payer: Ohio Health Group HMO |
$19.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.21
|
| Rate for Payer: PHCS Commercial |
$25.33
|
| Rate for Payer: United Healthcare All Payer |
$23.22
|
|
|
ED ARTERIAL BLOOD GAS STICK
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
HCPCS 36600
|
| Hospital Charge Code |
41000013
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$174.72 |
| Rate for Payer: Aetna Commercial |
$140.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$141.96
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cigna Commercial |
$151.06
|
| Rate for Payer: First Health Commercial |
$172.90
|
| Rate for Payer: Humana Commercial |
$154.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$149.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$134.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$160.16
|
| Rate for Payer: Ohio Health Group HMO |
$136.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$158.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.58
|
| Rate for Payer: PHCS Commercial |
$174.72
|
| Rate for Payer: United Healthcare All Payer |
$160.16
|
|
