|
EXC TUMOR - FOREARM - WRIST
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 25075
|
| Hospital Charge Code |
76100575
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.65 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$470.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.65
|
| Rate for Payer: Anthem Medicaid |
$173.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$613.73
|
| Rate for Payer: Healthspan PPO |
$426.07
|
| Rate for Payer: Humana Medicaid |
$173.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$401.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.13
|
| Rate for Payer: Molina Healthcare Passport |
$173.66
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$170.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.40
|
|
|
EXC TUMOR - FOREARM - WRIST
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
HCPCS 25075
|
| Hospital Charge Code |
76100575
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$84.50 |
| Max. Negotiated Rate |
$624.00 |
| Rate for Payer: Aetna Commercial |
$500.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$507.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$539.50
|
| Rate for Payer: First Health Commercial |
$617.50
|
| Rate for Payer: Humana Commercial |
$552.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$533.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$479.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$195.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$572.00
|
| Rate for Payer: Ohio Health Group HMO |
$487.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$84.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$201.50
|
| Rate for Payer: PHCS Commercial |
$624.00
|
| Rate for Payer: United Healthcare All Payer |
$572.00
|
|
|
EXC TUMOR - FOREARM - WRIST(P
|
Professional
|
Both
|
$650.00
|
|
|
Service Code
|
HCPCS 25075
|
| Hospital Charge Code |
761P0575
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$162.65 |
| Max. Negotiated Rate |
$650.00 |
| Rate for Payer: Aetna Commercial |
$470.38
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$162.65
|
| Rate for Payer: Anthem Medicaid |
$173.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$650.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cash Price |
$325.00
|
| Rate for Payer: Cigna Commercial |
$613.73
|
| Rate for Payer: Healthspan PPO |
$426.07
|
| Rate for Payer: Humana Medicaid |
$173.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$401.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.13
|
| Rate for Payer: Molina Healthcare Passport |
$173.66
|
| Rate for Payer: Multiplan PHCS |
$390.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$455.00
|
| Rate for Payer: UHCCP Medicaid |
$170.78
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.40
|
|
|
EXC TUMOR HAND OR FINGER
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
HCPCS 26115
|
| Hospital Charge Code |
76100668
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$1,962.83 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem Medicaid |
$292.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Humana KY Medicaid |
$292.32
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$295.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
EXC TUMOR HAND OR FINGER
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS 26115
|
| Hospital Charge Code |
76100668
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
EXC TUMOR HAND OR FINGER
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 26115
|
| Hospital Charge Code |
76100668
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$170.16 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$503.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$170.44
|
| Rate for Payer: Anthem Medicaid |
$170.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$562.63
|
| Rate for Payer: Healthspan PPO |
$755.44
|
| Rate for Payer: Humana Medicaid |
$170.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$419.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$173.56
|
| Rate for Payer: Molina Healthcare Passport |
$170.16
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$178.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.86
|
|
|
EXC TUMOR HAND OR FINGER(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 26115
|
| Hospital Charge Code |
761P0668
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$170.16 |
| Max. Negotiated Rate |
$850.00 |
| Rate for Payer: Aetna Commercial |
$503.25
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$170.44
|
| Rate for Payer: Anthem Medicaid |
$170.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$562.63
|
| Rate for Payer: Healthspan PPO |
$755.44
|
| Rate for Payer: Humana Medicaid |
$170.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$419.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$173.56
|
| Rate for Payer: Molina Healthcare Passport |
$170.16
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$595.00
|
| Rate for Payer: UHCCP Medicaid |
$178.96
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$171.86
|
|
|
EXC TUMOR PELVIS & HIP AREA
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27047
|
| Hospital Charge Code |
76100768
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$214.44 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$754.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$214.44
|
| Rate for Payer: Anthem Medicaid |
$268.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$810.71
|
| Rate for Payer: Healthspan PPO |
$800.89
|
| Rate for Payer: Humana Medicaid |
$268.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$474.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$273.94
|
| Rate for Payer: Molina Healthcare Passport |
$268.57
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$225.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$271.26
|
|
|
EXC TUMOR PELVIS & HIP AREA
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27047
|
| Hospital Charge Code |
76100768
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
EXC TUMOR PELVIS & HIP AREA
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27047
|
| Hospital Charge Code |
76100768
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
EXC TUMOR PELVIS & HIP AREA(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27047
|
| Hospital Charge Code |
761P0768
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$214.44 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$754.13
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$214.44
|
| Rate for Payer: Anthem Medicaid |
$268.57
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$810.71
|
| Rate for Payer: Healthspan PPO |
$800.89
|
| Rate for Payer: Humana Medicaid |
$268.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$474.52
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$273.94
|
| Rate for Payer: Molina Healthcare Passport |
$268.57
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$225.16
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$271.26
|
|
|
EXC. TUMOR - THIGH - DEEP
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS 27328
|
| Hospital Charge Code |
76100814
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$3,440.07 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem Medicaid |
$309.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,457.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,440.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,317.21
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Humana KY Medicaid |
$309.51
|
| Rate for Payer: Humana Medicare Advantage |
$2,457.19
|
| Rate for Payer: Kentucky WC Medicaid |
$312.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,948.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$315.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
EXC. TUMOR - THIGH - DEEP
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 27328
|
| Hospital Charge Code |
76100814
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.72 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$609.54
|
| Rate for Payer: Anthem Medicaid |
$282.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$658.28
|
| Rate for Payer: Healthspan PPO |
$552.12
|
| Rate for Payer: Humana Medicaid |
$282.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$733.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$288.37
|
| Rate for Payer: Molina Healthcare Passport |
$282.72
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$315.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$285.55
|
|
|
EXC. TUMOR - THIGH - DEEP
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS 27328
|
| Hospital Charge Code |
76100814
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$864.00 |
| Rate for Payer: Aetna Commercial |
$693.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$702.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$747.00
|
| Rate for Payer: First Health Commercial |
$855.00
|
| Rate for Payer: Humana Commercial |
$765.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$738.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$664.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$270.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$792.00
|
| Rate for Payer: Ohio Health Group HMO |
$675.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$180.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$279.00
|
| Rate for Payer: PHCS Commercial |
$864.00
|
| Rate for Payer: United Healthcare All Payer |
$792.00
|
|
|
EXC. TUMOR - THIGH - DEEP(P
|
Professional
|
Both
|
$900.00
|
|
|
Service Code
|
HCPCS 27328
|
| Hospital Charge Code |
761P0814
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$282.72 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$609.54
|
| Rate for Payer: Anthem Medicaid |
$282.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$900.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cash Price |
$450.00
|
| Rate for Payer: Cigna Commercial |
$658.28
|
| Rate for Payer: Healthspan PPO |
$552.12
|
| Rate for Payer: Humana Medicaid |
$282.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$733.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$288.37
|
| Rate for Payer: Molina Healthcare Passport |
$282.72
|
| Rate for Payer: Multiplan PHCS |
$540.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$630.00
|
| Rate for Payer: UHCCP Medicaid |
$315.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$285.55
|
|
|
EXECDRIN X/S CAP
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 46122038278
|
| Hospital Charge Code |
25000647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
EXECDRIN X/S CAP
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 46122038278
|
| Hospital Charge Code |
25000647
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
EXELON 13.3 MG 24HR PATCH
|
Facility
|
OP
|
$39.87
|
|
|
Service Code
|
NDC 78050315
|
| Hospital Charge Code |
25000650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$38.28 |
| Rate for Payer: Aetna Commercial |
$30.70
|
| Rate for Payer: Anthem Medicaid |
$13.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.10
|
| Rate for Payer: Cash Price |
$19.93
|
| Rate for Payer: Cigna Commercial |
$33.09
|
| Rate for Payer: First Health Commercial |
$37.88
|
| Rate for Payer: Humana Commercial |
$33.89
|
| Rate for Payer: Humana KY Medicaid |
$13.71
|
| Rate for Payer: Kentucky WC Medicaid |
$13.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.09
|
| Rate for Payer: Ohio Health Group HMO |
$29.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.36
|
| Rate for Payer: PHCS Commercial |
$38.28
|
| Rate for Payer: United Healthcare All Payer |
$35.09
|
|
|
EXELON 13.3 MG 24HR PATCH
|
Facility
|
IP
|
$39.87
|
|
|
Service Code
|
NDC 78050315
|
| Hospital Charge Code |
25000650
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$38.28 |
| Rate for Payer: Aetna Commercial |
$30.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.10
|
| Rate for Payer: Cash Price |
$19.93
|
| Rate for Payer: Cigna Commercial |
$33.09
|
| Rate for Payer: First Health Commercial |
$37.88
|
| Rate for Payer: Humana Commercial |
$33.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.09
|
| Rate for Payer: Ohio Health Group HMO |
$29.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.36
|
| Rate for Payer: PHCS Commercial |
$38.28
|
| Rate for Payer: United Healthcare All Payer |
$35.09
|
|
|
EXELON 4.6MG/24HR PATCH
|
Facility
|
OP
|
$30.52
|
|
|
Service Code
|
NDC 781730431
|
| Hospital Charge Code |
25000651
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$23.50
|
| Rate for Payer: Anthem Medicaid |
$10.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.81
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cigna Commercial |
$25.33
|
| Rate for Payer: First Health Commercial |
$28.99
|
| Rate for Payer: Humana Commercial |
$25.94
|
| Rate for Payer: Humana KY Medicaid |
$10.50
|
| Rate for Payer: Kentucky WC Medicaid |
$10.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.86
|
| Rate for Payer: Ohio Health Group HMO |
$22.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.46
|
| Rate for Payer: PHCS Commercial |
$29.30
|
| Rate for Payer: United Healthcare All Payer |
$26.86
|
|
|
EXELON 4.6MG/24HR PATCH
|
Facility
|
IP
|
$30.52
|
|
|
Service Code
|
NDC 781730431
|
| Hospital Charge Code |
25000651
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$23.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.81
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cigna Commercial |
$25.33
|
| Rate for Payer: First Health Commercial |
$28.99
|
| Rate for Payer: Humana Commercial |
$25.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.86
|
| Rate for Payer: Ohio Health Group HMO |
$22.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.46
|
| Rate for Payer: PHCS Commercial |
$29.30
|
| Rate for Payer: United Healthcare All Payer |
$26.86
|
|
|
EXELON 9.5MG/24HR PATCH
|
Facility
|
IP
|
$30.52
|
|
|
Service Code
|
NDC 781730931
|
| Hospital Charge Code |
25000652
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$23.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.81
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cigna Commercial |
$25.33
|
| Rate for Payer: First Health Commercial |
$28.99
|
| Rate for Payer: Humana Commercial |
$25.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.86
|
| Rate for Payer: Ohio Health Group HMO |
$22.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.46
|
| Rate for Payer: PHCS Commercial |
$29.30
|
| Rate for Payer: United Healthcare All Payer |
$26.86
|
|
|
EXELON 9.5MG/24HR PATCH
|
Facility
|
OP
|
$30.52
|
|
|
Service Code
|
NDC 781730931
|
| Hospital Charge Code |
25000652
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.97 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Humana Commercial |
$25.94
|
| Rate for Payer: Humana KY Medicaid |
$10.50
|
| Rate for Payer: Kentucky WC Medicaid |
$10.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.86
|
| Rate for Payer: Ohio Health Group HMO |
$22.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.46
|
| Rate for Payer: PHCS Commercial |
$29.30
|
| Rate for Payer: United Healthcare All Payer |
$26.86
|
| Rate for Payer: Aetna Commercial |
$23.50
|
| Rate for Payer: Anthem Medicaid |
$10.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.81
|
| Rate for Payer: Cash Price |
$15.26
|
| Rate for Payer: Cigna Commercial |
$25.33
|
| Rate for Payer: First Health Commercial |
$28.99
|
|
|
EXELON (RIVASTIGMINE) 1.5 MG T
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 55111035260
|
| Hospital Charge Code |
25000648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
EXELON (RIVASTIGMINE) 1.5 MG T
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 55111035260
|
| Hospital Charge Code |
25000648
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
|
