|
EST PT MID LEVEL 3(T
|
Facility
|
OP
|
$279.00
|
|
|
Service Code
|
HCPCS G0463
|
| Hospital Charge Code |
510T0008
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$267.84 |
| Rate for Payer: Aetna Commercial |
$214.83
|
| Rate for Payer: Anthem Medicaid |
$95.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$114.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$217.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$160.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$154.32
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cash Price |
$139.50
|
| Rate for Payer: Cigna Commercial |
$231.57
|
| Rate for Payer: First Health Commercial |
$265.05
|
| Rate for Payer: Humana Commercial |
$237.15
|
| Rate for Payer: Humana KY Medicaid |
$95.95
|
| Rate for Payer: Humana Medicare Advantage |
$114.31
|
| Rate for Payer: Kentucky WC Medicaid |
$96.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$228.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$205.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$137.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$97.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$245.52
|
| Rate for Payer: Ohio Health Group HMO |
$209.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$86.49
|
| Rate for Payer: PHCS Commercial |
$267.84
|
| Rate for Payer: United Healthcare All Payer |
$245.52
|
|
|
ESTRACE 0.01% VAG CRM (42.5GM)
|
Facility
|
OP
|
$22.44
|
|
|
Service Code
|
NDC 430375414
|
| Hospital Charge Code |
25000637
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$21.54 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Anthem Medicaid |
$7.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.50
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Cigna Commercial |
$18.63
|
| Rate for Payer: First Health Commercial |
$21.32
|
| Rate for Payer: Humana Commercial |
$19.07
|
| Rate for Payer: Humana KY Medicaid |
$7.72
|
| Rate for Payer: Kentucky WC Medicaid |
$7.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.75
|
| Rate for Payer: Ohio Health Group HMO |
$16.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.96
|
| Rate for Payer: PHCS Commercial |
$21.54
|
| Rate for Payer: United Healthcare All Payer |
$19.75
|
|
|
ESTRACE 0.01% VAG CRM (42.5GM)
|
Facility
|
IP
|
$22.44
|
|
|
Service Code
|
NDC 430375414
|
| Hospital Charge Code |
25000637
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$21.54 |
| Rate for Payer: Aetna Commercial |
$17.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.50
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Cigna Commercial |
$18.63
|
| Rate for Payer: First Health Commercial |
$21.32
|
| Rate for Payer: Humana Commercial |
$19.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.75
|
| Rate for Payer: Ohio Health Group HMO |
$16.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.96
|
| Rate for Payer: PHCS Commercial |
$21.54
|
| Rate for Payer: United Healthcare All Payer |
$19.75
|
|
|
ESTRACE (ESTRADIOL) 1 1MG/1TAB
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 555088602
|
| Hospital Charge Code |
25000636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
ESTRACE (ESTRADIOL) 1 1MG/1TAB
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 555088602
|
| Hospital Charge Code |
25000636
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| 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 |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
ESTRADIOL (10MG)20 MG/ML MDV
|
Facility
|
IP
|
$98.21
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636T0222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$94.28 |
| Rate for Payer: Aetna Commercial |
$75.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.60
|
| Rate for Payer: Cash Price |
$49.10
|
| Rate for Payer: Cigna Commercial |
$81.51
|
| Rate for Payer: First Health Commercial |
$93.30
|
| Rate for Payer: Humana Commercial |
$83.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.42
|
| Rate for Payer: Ohio Health Group HMO |
$73.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.45
|
| Rate for Payer: PHCS Commercial |
$94.28
|
| Rate for Payer: United Healthcare All Payer |
$86.42
|
|
|
ESTRADIOL (10MG)20 MG/ML MDV
|
Facility
|
OP
|
$98.21
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
636T0222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$94.28 |
| Rate for Payer: Aetna Commercial |
$75.62
|
| Rate for Payer: Anthem Medicaid |
$33.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.60
|
| Rate for Payer: Cash Price |
$49.10
|
| Rate for Payer: Cigna Commercial |
$81.51
|
| Rate for Payer: First Health Commercial |
$93.30
|
| Rate for Payer: Humana Commercial |
$83.48
|
| Rate for Payer: Humana KY Medicaid |
$33.77
|
| Rate for Payer: Kentucky WC Medicaid |
$34.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.42
|
| Rate for Payer: Ohio Health Group HMO |
$73.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.45
|
| Rate for Payer: PHCS Commercial |
$94.28
|
| Rate for Payer: United Healthcare All Payer |
$86.42
|
|
|
ESTRADIOL (10MG)20 MG/ML MDV
|
Facility
|
OP
|
$98.21
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
63600222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$94.28 |
| Rate for Payer: Aetna Commercial |
$75.62
|
| Rate for Payer: Anthem Medicaid |
$33.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.60
|
| Rate for Payer: Cash Price |
$49.10
|
| Rate for Payer: Cigna Commercial |
$81.51
|
| Rate for Payer: First Health Commercial |
$93.30
|
| Rate for Payer: Humana Commercial |
$83.48
|
| Rate for Payer: Humana KY Medicaid |
$33.77
|
| Rate for Payer: Kentucky WC Medicaid |
$34.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$34.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.42
|
| Rate for Payer: Ohio Health Group HMO |
$73.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.45
|
| Rate for Payer: PHCS Commercial |
$94.28
|
| Rate for Payer: United Healthcare All Payer |
$86.42
|
|
|
ESTRADIOL (10MG)20 MG/ML MDV
|
Facility
|
IP
|
$98.21
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
63600222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$94.28 |
| Rate for Payer: Aetna Commercial |
$75.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76.60
|
| Rate for Payer: Cash Price |
$49.10
|
| Rate for Payer: Cigna Commercial |
$81.51
|
| Rate for Payer: First Health Commercial |
$93.30
|
| Rate for Payer: Humana Commercial |
$83.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$86.42
|
| Rate for Payer: Ohio Health Group HMO |
$73.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$30.45
|
| Rate for Payer: PHCS Commercial |
$94.28
|
| Rate for Payer: United Healthcare All Payer |
$86.42
|
|
|
ESTRADIOL (10MG)20 MG/ML MDV
|
Professional
|
Both
|
$98.21
|
|
|
Service Code
|
HCPCS J1380
|
| Hospital Charge Code |
63600222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$98.21 |
| Rate for Payer: Aetna Commercial |
$15.42
|
| Rate for Payer: Buckeye Medicare Advantage |
$98.21
|
| Rate for Payer: Cash Price |
$49.10
|
| Rate for Payer: Cash Price |
$49.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$14.48
|
| Rate for Payer: Multiplan PHCS |
$58.93
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$68.75
|
| Rate for Payer: UHCCP Medicaid |
$34.37
|
|
|
ESTRADIOL 50MG PELLET
|
Facility
|
OP
|
$144.48
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
636T0228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$111.25
|
| Rate for Payer: Anthem Medicaid |
$49.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.69
|
| Rate for Payer: Cash Price |
$72.24
|
| Rate for Payer: Cigna Commercial |
$119.92
|
| Rate for Payer: First Health Commercial |
$137.26
|
| Rate for Payer: Humana Commercial |
$122.81
|
| Rate for Payer: Humana KY Medicaid |
$49.69
|
| Rate for Payer: Kentucky WC Medicaid |
$50.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.14
|
| Rate for Payer: Ohio Health Group HMO |
$108.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.79
|
| Rate for Payer: PHCS Commercial |
$138.70
|
| Rate for Payer: United Healthcare All Payer |
$127.14
|
|
|
ESTRADIOL 50MG PELLET
|
Facility
|
IP
|
$144.48
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
636T0228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$111.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.69
|
| Rate for Payer: Cash Price |
$72.24
|
| Rate for Payer: Cigna Commercial |
$119.92
|
| Rate for Payer: First Health Commercial |
$137.26
|
| Rate for Payer: Humana Commercial |
$122.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.14
|
| Rate for Payer: Ohio Health Group HMO |
$108.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.79
|
| Rate for Payer: PHCS Commercial |
$138.70
|
| Rate for Payer: United Healthcare All Payer |
$127.14
|
|
|
ESTRADIOL 50MG PELLET
|
Facility
|
OP
|
$144.48
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$111.25
|
| Rate for Payer: Anthem Medicaid |
$49.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.69
|
| Rate for Payer: Cash Price |
$72.24
|
| Rate for Payer: Cigna Commercial |
$119.92
|
| Rate for Payer: First Health Commercial |
$137.26
|
| Rate for Payer: Humana Commercial |
$122.81
|
| Rate for Payer: Humana KY Medicaid |
$49.69
|
| Rate for Payer: Kentucky WC Medicaid |
$50.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.14
|
| Rate for Payer: Ohio Health Group HMO |
$108.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.79
|
| Rate for Payer: PHCS Commercial |
$138.70
|
| Rate for Payer: United Healthcare All Payer |
$127.14
|
|
|
ESTRADIOL 50MG PELLET
|
Facility
|
IP
|
$144.48
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$138.70 |
| Rate for Payer: Aetna Commercial |
$111.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.69
|
| Rate for Payer: Cash Price |
$72.24
|
| Rate for Payer: Cigna Commercial |
$119.92
|
| Rate for Payer: First Health Commercial |
$137.26
|
| Rate for Payer: Humana Commercial |
$122.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$127.14
|
| Rate for Payer: Ohio Health Group HMO |
$108.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.79
|
| Rate for Payer: PHCS Commercial |
$138.70
|
| Rate for Payer: United Healthcare All Payer |
$127.14
|
|
|
ESTRADIOL 50MG PELLET
|
Professional
|
Both
|
$144.48
|
|
|
Service Code
|
HCPCS J7999
|
| Hospital Charge Code |
63600228
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.57 |
| Max. Negotiated Rate |
$144.48 |
| Rate for Payer: Buckeye Medicare Advantage |
$144.48
|
| Rate for Payer: Cash Price |
$72.24
|
| Rate for Payer: Multiplan PHCS |
$86.69
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$101.14
|
| Rate for Payer: UHCCP Medicaid |
$50.57
|
|
|
ESTRADIOL;TOTAL
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
HCPCS 82670
|
| Hospital Charge Code |
30000312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.94 |
| Max. Negotiated Rate |
$218.88 |
| Rate for Payer: Aetna Commercial |
$175.56
|
| Rate for Payer: Anthem Medicaid |
$27.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$27.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.94
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$189.24
|
| Rate for Payer: First Health Commercial |
$216.60
|
| Rate for Payer: Humana Commercial |
$193.80
|
| Rate for Payer: Humana KY Medicaid |
$27.94
|
| Rate for Payer: Humana Medicare Advantage |
$27.94
|
| Rate for Payer: Kentucky WC Medicaid |
$28.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$168.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$200.64
|
| Rate for Payer: Ohio Health Group HMO |
$171.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.68
|
| Rate for Payer: PHCS Commercial |
$218.88
|
| Rate for Payer: United Healthcare All Payer |
$200.64
|
|
|
ESTRADIOL;TOTAL
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
HCPCS 82670
|
| Hospital Charge Code |
30000312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.64 |
| Max. Negotiated Rate |
$218.88 |
| Rate for Payer: Aetna Commercial |
$175.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.08
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$189.24
|
| Rate for Payer: First Health Commercial |
$216.60
|
| Rate for Payer: Humana Commercial |
$193.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$186.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$168.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$200.64
|
| Rate for Payer: Ohio Health Group HMO |
$171.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.68
|
| Rate for Payer: PHCS Commercial |
$218.88
|
| Rate for Payer: United Healthcare All Payer |
$200.64
|
|
|
ESTRADIOL;TOTAL
|
Professional
|
Both
|
$228.00
|
|
|
Service Code
|
HCPCS 82670
|
| Hospital Charge Code |
30000312
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.76 |
| Max. Negotiated Rate |
$228.00 |
| Rate for Payer: Aetna Commercial |
$26.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$228.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cash Price |
$114.00
|
| Rate for Payer: Cigna Commercial |
$24.70
|
| Rate for Payer: Healthspan PPO |
$29.28
|
| Rate for Payer: Multiplan PHCS |
$136.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$159.60
|
| Rate for Payer: UHCCP Medicaid |
$79.80
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$16.76
|
|
|
ETHMOIDECTOMY; INTRANASAL, ANT
|
Facility
|
IP
|
$1,119.00
|
|
|
Service Code
|
HCPCS 31200
|
| Hospital Charge Code |
76101146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.47 |
| Max. Negotiated Rate |
$1,074.24 |
| Rate for Payer: Aetna Commercial |
$861.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$872.82
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cigna Commercial |
$928.77
|
| Rate for Payer: First Health Commercial |
$1,063.05
|
| Rate for Payer: Humana Commercial |
$951.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$917.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$825.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$335.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$984.72
|
| Rate for Payer: Ohio Health Group HMO |
$839.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$223.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$145.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$346.89
|
| Rate for Payer: PHCS Commercial |
$1,074.24
|
| Rate for Payer: United Healthcare All Payer |
$984.72
|
|
|
ETHMOIDECTOMY; INTRANASAL, ANT
|
Professional
|
Both
|
$1,119.00
|
|
|
Service Code
|
HCPCS 31200
|
| Hospital Charge Code |
761P1146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$272.91 |
| Max. Negotiated Rate |
$1,119.00 |
| Rate for Payer: Aetna Commercial |
$735.99
|
| Rate for Payer: Anthem Medicaid |
$272.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,119.00
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cigna Commercial |
$786.90
|
| Rate for Payer: Healthspan PPO |
$620.68
|
| Rate for Payer: Humana Medicaid |
$272.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$684.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$278.37
|
| Rate for Payer: Molina Healthcare Passport |
$272.91
|
| Rate for Payer: Multiplan PHCS |
$671.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$783.30
|
| Rate for Payer: UHCCP Medicaid |
$391.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$275.64
|
|
|
ETHMOIDECTOMY; INTRANASAL, ANT
|
Professional
|
Both
|
$1,119.00
|
|
|
Service Code
|
HCPCS 31200
|
| Hospital Charge Code |
76101146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$272.91 |
| Max. Negotiated Rate |
$1,119.00 |
| Rate for Payer: Aetna Commercial |
$735.99
|
| Rate for Payer: Anthem Medicaid |
$272.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,119.00
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cigna Commercial |
$786.90
|
| Rate for Payer: Healthspan PPO |
$620.68
|
| Rate for Payer: Humana Medicaid |
$272.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$684.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$278.37
|
| Rate for Payer: Molina Healthcare Passport |
$272.91
|
| Rate for Payer: Multiplan PHCS |
$671.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$783.30
|
| Rate for Payer: UHCCP Medicaid |
$391.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$275.64
|
|
|
ETHMOIDECTOMY; INTRANASAL, ANT
|
Facility
|
OP
|
$1,119.00
|
|
|
Service Code
|
HCPCS 31200
|
| Hospital Charge Code |
76101146
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.47 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$861.63
|
| Rate for Payer: Anthem Medicaid |
$384.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$872.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cash Price |
$559.50
|
| Rate for Payer: Cigna Commercial |
$928.77
|
| Rate for Payer: First Health Commercial |
$1,063.05
|
| Rate for Payer: Humana Commercial |
$951.15
|
| Rate for Payer: Humana KY Medicaid |
$384.82
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$388.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$917.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$825.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$392.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$984.72
|
| Rate for Payer: Ohio Health Group HMO |
$839.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$223.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$145.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$346.89
|
| Rate for Payer: PHCS Commercial |
$1,074.24
|
| Rate for Payer: United Healthcare All Payer |
$984.72
|
|
|
ETHYL CHLORIDE100SPRAY/103.5ML
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 386000104
|
| Hospital Charge Code |
25003819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna Commercial |
$1.46
|
| Rate for Payer: Anthem Medicaid |
$0.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.47
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna Commercial |
$1.57
|
| Rate for Payer: First Health Commercial |
$1.80
|
| Rate for Payer: Humana Commercial |
$1.61
|
| Rate for Payer: Humana KY Medicaid |
$0.65
|
| Rate for Payer: Kentucky WC Medicaid |
$0.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.66
|
| Rate for Payer: Ohio Health Group HMO |
$1.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.59
|
| Rate for Payer: PHCS Commercial |
$1.81
|
| Rate for Payer: United Healthcare All Payer |
$1.66
|
|
|
ETHYL CHLORIDE100SPRAY/103.5ML
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 386000104
|
| Hospital Charge Code |
25003819
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.81 |
| Rate for Payer: Aetna Commercial |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.47
|
| Rate for Payer: Cash Price |
$0.94
|
| Rate for Payer: Cigna Commercial |
$1.57
|
| Rate for Payer: First Health Commercial |
$1.80
|
| Rate for Payer: Humana Commercial |
$1.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.66
|
| Rate for Payer: Ohio Health Group HMO |
$1.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.59
|
| Rate for Payer: PHCS Commercial |
$1.81
|
| Rate for Payer: United Healthcare All Payer |
$1.66
|
|
|
ETHYOL(AMIFOSTINE) 500MG/10ML
|
Facility
|
OP
|
$5,839.18
|
|
|
Service Code
|
HCPCS J0207
|
| Hospital Charge Code |
25001840
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$759.09 |
| Max. Negotiated Rate |
$5,605.61 |
| Rate for Payer: Aetna Commercial |
$4,496.17
|
| Rate for Payer: Anthem Medicaid |
$2,008.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,554.56
|
| Rate for Payer: Cash Price |
$2,919.59
|
| Rate for Payer: Cigna Commercial |
$4,846.52
|
| Rate for Payer: First Health Commercial |
$5,547.22
|
| Rate for Payer: Humana Commercial |
$4,963.30
|
| Rate for Payer: Humana KY Medicaid |
$2,008.09
|
| Rate for Payer: Kentucky WC Medicaid |
$2,028.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,788.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,309.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,751.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,048.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,138.48
|
| Rate for Payer: Ohio Health Group HMO |
$4,379.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,167.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$759.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,810.15
|
| Rate for Payer: PHCS Commercial |
$5,605.61
|
| Rate for Payer: United Healthcare All Payer |
$5,138.48
|
|
