|
FOREIGN BODYEYE SCRNG FOR MR(T
|
Facility
|
OP
|
$474.00
|
|
|
Service Code
|
HCPCS 70030
|
| Hospital Charge Code |
320T0010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$455.04 |
| Rate for Payer: Aetna Commercial |
$364.98
|
| Rate for Payer: Anthem Medicaid |
$163.01
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$78.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$369.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$110.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$106.08
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cash Price |
$237.00
|
| Rate for Payer: Cigna Commercial |
$393.42
|
| Rate for Payer: First Health Commercial |
$450.30
|
| Rate for Payer: Humana Commercial |
$402.90
|
| Rate for Payer: Humana KY Medicaid |
$163.01
|
| Rate for Payer: Humana Medicare Advantage |
$78.58
|
| Rate for Payer: Kentucky WC Medicaid |
$164.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$388.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$349.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$94.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$166.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$417.12
|
| Rate for Payer: Ohio Health Group HMO |
$355.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$94.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$146.94
|
| Rate for Payer: PHCS Commercial |
$455.04
|
| Rate for Payer: United Healthcare All Payer |
$417.12
|
|
|
FORESKIN MANIPULATION
|
Professional
|
Both
|
$1,214.60
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
76102136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$1,214.60 |
| Rate for Payer: Aetna Commercial |
$97.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.73
|
| Rate for Payer: Anthem Medicaid |
$52.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,214.60
|
| Rate for Payer: Cash Price |
$607.30
|
| Rate for Payer: Cash Price |
$607.30
|
| Rate for Payer: Cigna Commercial |
$115.45
|
| Rate for Payer: Healthspan PPO |
$114.76
|
| Rate for Payer: Humana Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.86
|
| Rate for Payer: Molina Healthcare Passport |
$52.80
|
| Rate for Payer: Multiplan PHCS |
$728.76
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$850.22
|
| Rate for Payer: UHCCP Medicaid |
$40.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.33
|
|
|
FORESKIN MANIPULATION
|
Facility
|
IP
|
$503.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
45000285
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$65.39 |
| Max. Negotiated Rate |
$482.88 |
| Rate for Payer: Aetna Commercial |
$387.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$392.34
|
| Rate for Payer: Cash Price |
$251.50
|
| Rate for Payer: Cigna Commercial |
$417.49
|
| Rate for Payer: First Health Commercial |
$477.85
|
| Rate for Payer: Humana Commercial |
$427.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$412.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$442.64
|
| Rate for Payer: Ohio Health Group HMO |
$377.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.93
|
| Rate for Payer: PHCS Commercial |
$482.88
|
| Rate for Payer: United Healthcare All Payer |
$442.64
|
|
|
FORESKIN MANIPULATION
|
Facility
|
OP
|
$1,214.60
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
76102136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.90 |
| Max. Negotiated Rate |
$1,166.02 |
| Rate for Payer: Aetna Commercial |
$935.24
|
| Rate for Payer: Anthem Medicaid |
$417.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$947.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$607.30
|
| Rate for Payer: Cash Price |
$607.30
|
| Rate for Payer: Cigna Commercial |
$1,008.12
|
| Rate for Payer: First Health Commercial |
$1,153.87
|
| Rate for Payer: Humana Commercial |
$1,032.41
|
| Rate for Payer: Humana KY Medicaid |
$417.70
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$421.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$995.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$896.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$426.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,068.85
|
| Rate for Payer: Ohio Health Group HMO |
$910.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.53
|
| Rate for Payer: PHCS Commercial |
$1,166.02
|
| Rate for Payer: United Healthcare All Payer |
$1,068.85
|
|
|
FORESKIN MANIPULATION
|
Facility
|
IP
|
$1,214.60
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
76102136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.90 |
| Max. Negotiated Rate |
$1,166.02 |
| Rate for Payer: Aetna Commercial |
$935.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$947.39
|
| Rate for Payer: Cash Price |
$607.30
|
| Rate for Payer: Cigna Commercial |
$1,008.12
|
| Rate for Payer: First Health Commercial |
$1,153.87
|
| Rate for Payer: Humana Commercial |
$1,032.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$995.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$896.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$364.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,068.85
|
| Rate for Payer: Ohio Health Group HMO |
$910.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$242.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$157.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$376.53
|
| Rate for Payer: PHCS Commercial |
$1,166.02
|
| Rate for Payer: United Healthcare All Payer |
$1,068.85
|
|
|
FORESKIN MANIPULATION
|
Facility
|
OP
|
$503.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
45000285
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$65.39 |
| Max. Negotiated Rate |
$482.88 |
| Rate for Payer: Aetna Commercial |
$387.31
|
| Rate for Payer: Anthem Medicaid |
$172.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$392.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$251.50
|
| Rate for Payer: Cash Price |
$251.50
|
| Rate for Payer: Cigna Commercial |
$417.49
|
| Rate for Payer: First Health Commercial |
$477.85
|
| Rate for Payer: Humana Commercial |
$427.55
|
| Rate for Payer: Humana KY Medicaid |
$172.98
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$174.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$412.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$371.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$176.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$442.64
|
| Rate for Payer: Ohio Health Group HMO |
$377.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$100.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$155.93
|
| Rate for Payer: PHCS Commercial |
$482.88
|
| Rate for Payer: United Healthcare All Payer |
$442.64
|
|
|
FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS AND STRETCHING
|
Facility
|
OP
|
$299.21
|
|
|
Service Code
|
CPT 54450
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$213.72 |
| Max. Negotiated Rate |
$299.21 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
|
|
FORESKIN MANIPULATION(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
761P2136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.73 |
| Max. Negotiated Rate |
$350.00 |
| Rate for Payer: Aetna Commercial |
$97.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.73
|
| Rate for Payer: Anthem Medicaid |
$52.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$350.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$115.45
|
| Rate for Payer: Healthspan PPO |
$114.76
|
| Rate for Payer: Humana Medicaid |
$52.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$78.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.86
|
| Rate for Payer: Molina Healthcare Passport |
$52.80
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$40.67
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$53.33
|
|
|
FORESKIN MANIPULATION(T
|
Facility
|
IP
|
$864.60
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
761T2136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$830.02 |
| Rate for Payer: Aetna Commercial |
$665.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$674.39
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cigna Commercial |
$717.62
|
| Rate for Payer: First Health Commercial |
$821.37
|
| Rate for Payer: Humana Commercial |
$734.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$708.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$638.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$259.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$760.85
|
| Rate for Payer: Ohio Health Group HMO |
$648.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$268.03
|
| Rate for Payer: PHCS Commercial |
$830.02
|
| Rate for Payer: United Healthcare All Payer |
$760.85
|
|
|
FORESKIN MANIPULATION(T
|
Facility
|
OP
|
$864.60
|
|
|
Service Code
|
HCPCS 54450
|
| Hospital Charge Code |
761T2136
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$112.40 |
| Max. Negotiated Rate |
$830.02 |
| Rate for Payer: Aetna Commercial |
$665.74
|
| Rate for Payer: Anthem Medicaid |
$297.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$213.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$674.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$299.21
|
| Rate for Payer: CareSource Just4Me Medicare |
$288.52
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cash Price |
$432.30
|
| Rate for Payer: Cigna Commercial |
$717.62
|
| Rate for Payer: First Health Commercial |
$821.37
|
| Rate for Payer: Humana Commercial |
$734.91
|
| Rate for Payer: Humana KY Medicaid |
$297.34
|
| Rate for Payer: Humana Medicare Advantage |
$213.72
|
| Rate for Payer: Kentucky WC Medicaid |
$300.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$708.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$638.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$256.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$303.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$760.85
|
| Rate for Payer: Ohio Health Group HMO |
$648.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$172.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$112.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$268.03
|
| Rate for Payer: PHCS Commercial |
$830.02
|
| Rate for Payer: United Healthcare All Payer |
$760.85
|
|
|
FORTAZ 500MG (1 GRAM)
|
Facility
|
OP
|
$80.50
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
25003810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Anthem Medicaid |
$27.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.79
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cigna Commercial |
$66.82
|
| Rate for Payer: First Health Commercial |
$76.48
|
| Rate for Payer: Humana Commercial |
$68.42
|
| Rate for Payer: Humana KY Medicaid |
$27.68
|
| Rate for Payer: Kentucky WC Medicaid |
$27.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.84
|
| Rate for Payer: Ohio Health Group HMO |
$60.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.96
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
| Rate for Payer: Aetna Commercial |
$61.98
|
|
|
FORTAZ 500MG (1 GRAM)
|
Facility
|
IP
|
$80.50
|
|
|
Service Code
|
HCPCS J0713
|
| Hospital Charge Code |
25003810
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$77.28 |
| Rate for Payer: Aetna Commercial |
$61.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.79
|
| Rate for Payer: Cash Price |
$40.25
|
| Rate for Payer: Cigna Commercial |
$66.82
|
| Rate for Payer: First Health Commercial |
$76.48
|
| Rate for Payer: Humana Commercial |
$68.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.84
|
| Rate for Payer: Ohio Health Group HMO |
$60.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.96
|
| Rate for Payer: PHCS Commercial |
$77.28
|
| Rate for Payer: United Healthcare All Payer |
$70.84
|
|
|
FORTRESS DEST SHTH ST 4F 45CM
|
Facility
|
IP
|
$1,565.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.45 |
| Max. Negotiated Rate |
$1,502.40 |
| Rate for Payer: Aetna Commercial |
$1,205.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,220.70
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,298.95
|
| Rate for Payer: First Health Commercial |
$1,486.75
|
| Rate for Payer: Humana Commercial |
$1,330.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,283.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,377.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$313.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$485.15
|
| Rate for Payer: PHCS Commercial |
$1,502.40
|
| Rate for Payer: United Healthcare All Payer |
$1,377.20
|
|
|
FORTRESS DEST SHTH ST 4F 45CM
|
Facility
|
OP
|
$1,565.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.45 |
| Max. Negotiated Rate |
$1,502.40 |
| Rate for Payer: Aetna Commercial |
$1,205.05
|
| Rate for Payer: Anthem Medicaid |
$538.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,220.70
|
| Rate for Payer: Cash Price |
$782.50
|
| Rate for Payer: Cigna Commercial |
$1,298.95
|
| Rate for Payer: First Health Commercial |
$1,486.75
|
| Rate for Payer: Humana Commercial |
$1,330.25
|
| Rate for Payer: Humana KY Medicaid |
$538.20
|
| Rate for Payer: Kentucky WC Medicaid |
$543.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,283.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$549.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,377.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$313.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$485.15
|
| Rate for Payer: PHCS Commercial |
$1,502.40
|
| Rate for Payer: United Healthcare All Payer |
$1,377.20
|
|
|
FORTRESS DEST SHTH ST 6F 45CM
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
FORTRESS DEST SHTH ST 6F 45CM
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
FOSAMAX (ALENDRONATE 10MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 64980034001
|
| Hospital Charge Code |
25000703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
FOSAMAX (ALENDRONATE 10MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 64980034001
|
| Hospital Charge Code |
25000703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
FOSAMAX (ALENDRON SOD)70MG TAB
|
Facility
|
OP
|
$4.83
|
|
|
Service Code
|
NDC 64980034214
|
| Hospital Charge Code |
25000702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.01
|
| Rate for Payer: First Health Commercial |
$4.59
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.25
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Payer |
$4.25
|
|
|
FOSAMAX (ALENDRON SOD)70MG TAB
|
Facility
|
IP
|
$4.83
|
|
|
Service Code
|
NDC 64980034214
|
| Hospital Charge Code |
25000702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.01
|
| Rate for Payer: First Health Commercial |
$4.59
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.25
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Payer |
$4.25
|
|
|
FOSRENOL 500MG CHEW TAB
|
Facility
|
IP
|
$29.01
|
|
|
Service Code
|
NDC 54092025290
|
| Hospital Charge Code |
25000704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Aetna Commercial |
$22.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.63
|
| Rate for Payer: Cash Price |
$14.51
|
| Rate for Payer: Cigna Commercial |
$24.08
|
| Rate for Payer: First Health Commercial |
$27.56
|
| Rate for Payer: Humana Commercial |
$24.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.53
|
| Rate for Payer: Ohio Health Group HMO |
$21.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.99
|
| Rate for Payer: PHCS Commercial |
$27.85
|
| Rate for Payer: United Healthcare All Payer |
$25.53
|
|
|
FOSRENOL 500MG CHEW TAB
|
Facility
|
OP
|
$29.01
|
|
|
Service Code
|
NDC 54092025290
|
| Hospital Charge Code |
25000704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Aetna Commercial |
$22.34
|
| Rate for Payer: Anthem Medicaid |
$9.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.63
|
| Rate for Payer: Cash Price |
$14.51
|
| Rate for Payer: Cigna Commercial |
$24.08
|
| Rate for Payer: First Health Commercial |
$27.56
|
| Rate for Payer: Humana Commercial |
$24.66
|
| Rate for Payer: Humana KY Medicaid |
$9.98
|
| Rate for Payer: Kentucky WC Medicaid |
$10.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.53
|
| Rate for Payer: Ohio Health Group HMO |
$21.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.99
|
| Rate for Payer: PHCS Commercial |
$27.85
|
| Rate for Payer: United Healthcare All Payer |
$25.53
|
|
|
FRACTURES OF FEMUR WITH MCC
|
Facility
|
IP
|
$19,084.45
|
|
|
Service Code
|
MSDRG 533
|
| Min. Negotiated Rate |
$12,950.16 |
| Max. Negotiated Rate |
$19,084.45 |
| Rate for Payer: Anthem Medicaid |
$12,950.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13,631.75
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19,084.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$18,402.86
|
| Rate for Payer: Humana KY Medicaid |
$12,950.16
|
| Rate for Payer: Humana Medicare Advantage |
$13,631.75
|
| Rate for Payer: Kentucky WC Medicaid |
$13,079.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,358.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,209.17
|
|
|
FRACTURES OF FEMUR WITHOUT MCC
|
Facility
|
IP
|
$9,475.54
|
|
|
Service Code
|
MSDRG 534
|
| Min. Negotiated Rate |
$6,429.83 |
| Max. Negotiated Rate |
$9,475.54 |
| Rate for Payer: Anthem Medicaid |
$6,429.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,768.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,475.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,137.12
|
| Rate for Payer: Humana KY Medicaid |
$6,429.83
|
| Rate for Payer: Humana Medicare Advantage |
$6,768.24
|
| Rate for Payer: Kentucky WC Medicaid |
$6,494.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,121.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,558.42
|
|
|
FRACTURES OF HIP AND PELVIS WITH MCC
|
Facility
|
IP
|
$15,169.06
|
|
|
Service Code
|
MSDRG 535
|
| Min. Negotiated Rate |
$10,293.29 |
| Max. Negotiated Rate |
$15,169.06 |
| Rate for Payer: Anthem Medicaid |
$10,293.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,835.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15,169.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,627.30
|
| Rate for Payer: Humana KY Medicaid |
$10,293.29
|
| Rate for Payer: Humana Medicare Advantage |
$10,835.04
|
| Rate for Payer: Kentucky WC Medicaid |
$10,396.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,002.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,499.15
|
|
