|
HALDOL 10MG/5ML ORAL SUSP
|
Facility
|
IP
|
$4.20
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004546
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Aetna Commercial |
$3.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cigna Commercial |
$3.49
|
| Rate for Payer: First Health Commercial |
$3.99
|
| Rate for Payer: Humana Commercial |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.70
|
| Rate for Payer: Ohio Health Group HMO |
$3.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.90
|
| Rate for Payer: PHCS Commercial |
$4.03
|
| Rate for Payer: United Healthcare All Payer |
$3.70
|
|
|
HALDOL DECAN EQ50MG 100MG/ML V
|
Facility
|
IP
|
$320.48
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
25002123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.14 |
| Max. Negotiated Rate |
$307.66 |
| Rate for Payer: Aetna Commercial |
$246.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.97
|
| Rate for Payer: Cash Price |
$160.24
|
| Rate for Payer: Cigna Commercial |
$266.00
|
| Rate for Payer: First Health Commercial |
$304.46
|
| Rate for Payer: Humana Commercial |
$272.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.02
|
| Rate for Payer: Ohio Health Group HMO |
$240.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.13
|
| Rate for Payer: PHCS Commercial |
$307.66
|
| Rate for Payer: United Healthcare All Payer |
$282.02
|
|
|
HALDOL DECAN EQ50MG 100MG/ML V
|
Facility
|
OP
|
$320.48
|
|
|
Service Code
|
HCPCS J1631
|
| Hospital Charge Code |
25002123
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.14 |
| Max. Negotiated Rate |
$307.66 |
| Rate for Payer: Aetna Commercial |
$246.77
|
| Rate for Payer: Anthem Medicaid |
$110.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$249.97
|
| Rate for Payer: Cash Price |
$160.24
|
| Rate for Payer: Cigna Commercial |
$266.00
|
| Rate for Payer: First Health Commercial |
$304.46
|
| Rate for Payer: Humana Commercial |
$272.41
|
| Rate for Payer: Humana KY Medicaid |
$110.21
|
| Rate for Payer: Kentucky WC Medicaid |
$111.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$262.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$236.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$96.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$112.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$282.02
|
| Rate for Payer: Ohio Health Group HMO |
$240.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$256.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$278.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$221.13
|
| Rate for Payer: PHCS Commercial |
$307.66
|
| Rate for Payer: United Healthcare All Payer |
$282.02
|
|
|
HALDOL (HALOPERIDOL) 1MG/1TAB
|
Facility
|
OP
|
$4.57
|
|
|
Service Code
|
NDC 378025701
|
| Hospital Charge Code |
25000744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
HALDOL (HALOPERIDOL) 1MG/1TAB
|
Facility
|
IP
|
$4.57
|
|
|
Service Code
|
NDC 378025701
|
| Hospital Charge Code |
25000744
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.39 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.79
|
| Rate for Payer: First Health Commercial |
$4.34
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.02
|
| Rate for Payer: Ohio Health Group HMO |
$3.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.39
|
| Rate for Payer: United Healthcare All Payer |
$4.02
|
|
|
HALDOL (HALOPERIDOL) 2MG/1TAB
|
Facility
|
OP
|
$4.76
|
|
|
Service Code
|
NDC 51079073520
|
| Hospital Charge Code |
25000745
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: First Health Commercial |
$4.52
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.19
|
| Rate for Payer: Ohio Health Group HMO |
$3.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
|
|
HALDOL (HALOPERIDOL) 2MG/1TAB
|
Facility
|
IP
|
$4.76
|
|
|
Service Code
|
NDC 51079073520
|
| Hospital Charge Code |
25000745
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.57 |
| Rate for Payer: Aetna Commercial |
$3.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.95
|
| Rate for Payer: First Health Commercial |
$4.52
|
| Rate for Payer: Humana Commercial |
$4.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.19
|
| Rate for Payer: Ohio Health Group HMO |
$3.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.57
|
| Rate for Payer: United Healthcare All Payer |
$4.19
|
|
|
HALDOL (HALOPERIDOL) 5MG/1TAB
|
Facility
|
OP
|
$4.82
|
|
|
Service Code
|
NDC 68382007901
|
| Hospital Charge Code |
25000746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Cash Price |
$2.41
|
| Rate for Payer: Cigna Commercial |
$4.00
|
| Rate for Payer: First Health Commercial |
$4.58
|
| Rate for Payer: Humana Commercial |
$4.10
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.95
|
| 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 |
$4.24
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
|
HALDOL (HALOPERIDOL) 5MG/1TAB
|
Facility
|
IP
|
$4.82
|
|
|
Service Code
|
NDC 68382007901
|
| Hospital Charge Code |
25000746
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Cash Price |
$2.41
|
| Rate for Payer: Cigna Commercial |
$4.00
|
| Rate for Payer: First Health Commercial |
$4.58
|
| Rate for Payer: Humana Commercial |
$4.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.95
|
| 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 |
$4.24
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
|
HALDOL (HALOPERIDOL) .5MG/1TAB
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 378035101
|
| Hospital Charge Code |
25000747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
HALDOL (HALOPERIDOL) .5MG/1TAB
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 378035101
|
| Hospital Charge Code |
25000747
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.08
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
Half Leg Laser Hair Removal
|
Facility
|
IP
|
$350.00
|
|
| Hospital Charge Code |
22200188
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$290.50
|
| Rate for Payer: First Health Commercial |
$332.50
|
| Rate for Payer: Humana Commercial |
$297.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.00
|
| Rate for Payer: Ohio Health Group HMO |
$262.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$304.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.50
|
| Rate for Payer: PHCS Commercial |
$336.00
|
| Rate for Payer: United Healthcare All Payer |
$308.00
|
|
|
Half Leg Laser Hair Removal
|
Professional
|
Both
|
$350.00
|
|
| Hospital Charge Code |
22200188
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$122.50 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$245.00
|
| Rate for Payer: UHCCP Medicaid |
$122.50
|
|
|
Half Leg Laser Hair Removal
|
Facility
|
OP
|
$350.00
|
|
| Hospital Charge Code |
22200188
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$336.00 |
| Rate for Payer: Aetna Commercial |
$269.50
|
| Rate for Payer: Anthem Medicaid |
$120.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$290.50
|
| Rate for Payer: First Health Commercial |
$332.50
|
| Rate for Payer: Humana Commercial |
$297.50
|
| Rate for Payer: Humana KY Medicaid |
$120.36
|
| Rate for Payer: Kentucky WC Medicaid |
$121.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$287.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$258.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$105.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$122.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$308.00
|
| Rate for Payer: Ohio Health Group HMO |
$262.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$304.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.50
|
| Rate for Payer: PHCS Commercial |
$336.00
|
| Rate for Payer: United Healthcare All Payer |
$308.00
|
|
|
Half Leg LsrHairRem-PP#1 50%
|
Professional
|
Both
|
$446.00
|
|
| Hospital Charge Code |
22200352
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$156.10 |
| Max. Negotiated Rate |
$312.20 |
| Rate for Payer: Cash Price |
$223.00
|
| Rate for Payer: Multiplan PHCS |
$267.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$312.20
|
| Rate for Payer: UHCCP Medicaid |
$156.10
|
|
|
Half Leg LsrHairRem-PP#2/3 25%
|
Professional
|
Both
|
$223.00
|
|
| Hospital Charge Code |
22200468
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$78.05 |
| Max. Negotiated Rate |
$156.10 |
| Rate for Payer: Cash Price |
$111.50
|
| Rate for Payer: Multiplan PHCS |
$133.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$156.10
|
| Rate for Payer: UHCCP Medicaid |
$78.05
|
|
|
HALO ARMS
|
Professional
|
Both
|
$750.00
|
|
| Hospital Charge Code |
22200230
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
|
|
Halo Arms - PP #1 50%
|
Professional
|
Both
|
$956.00
|
|
| Hospital Charge Code |
22200231
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$334.60 |
| Max. Negotiated Rate |
$669.20 |
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Multiplan PHCS |
$573.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$669.20
|
| Rate for Payer: UHCCP Medicaid |
$334.60
|
|
|
Halo Arms - PP #2/3 25%
|
Professional
|
Both
|
$478.00
|
|
| Hospital Charge Code |
22200481
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$167.30 |
| Max. Negotiated Rate |
$334.60 |
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Multiplan PHCS |
$286.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$334.60
|
| Rate for Payer: UHCCP Medicaid |
$167.30
|
|
|
HALO CHEST
|
Professional
|
Both
|
$750.00
|
|
| Hospital Charge Code |
22200228
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$262.50 |
| Max. Negotiated Rate |
$525.00 |
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
|
|
Halo Chest - PP #1 50%
|
Professional
|
Both
|
$956.00
|
|
| Hospital Charge Code |
22200229
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$334.60 |
| Max. Negotiated Rate |
$669.20 |
| Rate for Payer: Cash Price |
$478.00
|
| Rate for Payer: Multiplan PHCS |
$573.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$669.20
|
| Rate for Payer: UHCCP Medicaid |
$334.60
|
|
|
Halo Chest - PP #2/3 25%
|
Professional
|
Both
|
$478.00
|
|
| Hospital Charge Code |
22200480
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$167.30 |
| Max. Negotiated Rate |
$334.60 |
| Rate for Payer: Cash Price |
$239.00
|
| Rate for Payer: Multiplan PHCS |
$286.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$334.60
|
| Rate for Payer: UHCCP Medicaid |
$167.30
|
|
|
HALO FULL FACE
|
Professional
|
Both
|
$1,300.00
|
|
| Hospital Charge Code |
22200224
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$910.00 |
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
|
|
Halo Full Face -PP #1 50%
|
Professional
|
Both
|
$1,659.00
|
|
| Hospital Charge Code |
22200225
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$580.65 |
| Max. Negotiated Rate |
$1,161.30 |
| Rate for Payer: Cash Price |
$829.50
|
| Rate for Payer: Multiplan PHCS |
$995.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,161.30
|
| Rate for Payer: UHCCP Medicaid |
$580.65
|
|
|
Halo Full Face-PP#2/3 25%
|
Professional
|
Both
|
$828.00
|
|
| Hospital Charge Code |
22200478
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$289.80 |
| Max. Negotiated Rate |
$579.60 |
| Rate for Payer: Cash Price |
$414.00
|
| Rate for Payer: Multiplan PHCS |
$496.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$579.60
|
| Rate for Payer: UHCCP Medicaid |
$289.80
|
|
