|
INSRT XLPE POLCP NON-CEM 61/28
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSRT XLPE POLCP NON-CEM 63/28
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSRT XLPE POLCP NON-CEM 63/28
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSRT XLPE POLCP NON-CEM 65/28
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSRT XLPE POLCP NON-CEM 65/28
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSRT XLPE POLCP NON-CEM 67/28
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSRT XLPE POLCP NON-CEM 67/28
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSTA-CHAR AQUEOUS 25GM/120ML
|
Facility
|
OP
|
$30.36
|
|
|
Service Code
|
NDC 574052174
|
| Hospital Charge Code |
25000784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem Medicaid |
$10.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Humana KY Medicaid |
$10.44
|
| Rate for Payer: Kentucky WC Medicaid |
$10.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.41
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-CHAR AQUEOUS 25GM/120ML
|
Facility
|
IP
|
$30.36
|
|
|
Service Code
|
NDC 574052174
|
| Hospital Charge Code |
25000784
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.41
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-CHAR SORBITOL 25GM/120ML
|
Facility
|
IP
|
$30.36
|
|
|
Service Code
|
NDC 574052074
|
| Hospital Charge Code |
25000785
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.41
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-CHAR SORBITOL 25GM/120ML
|
Facility
|
OP
|
$30.36
|
|
|
Service Code
|
NDC 574052074
|
| Hospital Charge Code |
25000785
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.95 |
| Max. Negotiated Rate |
$29.15 |
| Rate for Payer: Aetna Commercial |
$23.38
|
| Rate for Payer: Anthem Medicaid |
$10.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.68
|
| Rate for Payer: Cash Price |
$15.18
|
| Rate for Payer: Cigna Commercial |
$25.20
|
| Rate for Payer: First Health Commercial |
$28.84
|
| Rate for Payer: Humana Commercial |
$25.81
|
| Rate for Payer: Humana KY Medicaid |
$10.44
|
| Rate for Payer: Kentucky WC Medicaid |
$10.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.72
|
| Rate for Payer: Ohio Health Group HMO |
$22.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.41
|
| Rate for Payer: PHCS Commercial |
$29.15
|
| Rate for Payer: United Healthcare All Payer |
$26.72
|
|
|
INSTA-GLUCOSE TUBE 31 GM 31GM
|
Facility
|
OP
|
$11.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$8.59
|
| Rate for Payer: Anthem Medicaid |
$3.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.70
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.26
|
| Rate for Payer: First Health Commercial |
$10.60
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Humana KY Medicaid |
$3.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.82
|
| Rate for Payer: Ohio Health Group HMO |
$8.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$10.71
|
| Rate for Payer: United Healthcare All Payer |
$9.82
|
|
|
INSTA-GLUCOSE TUBE 31 GM 31GM
|
Facility
|
IP
|
$11.16
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25000786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$10.71 |
| Rate for Payer: Aetna Commercial |
$8.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.70
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna Commercial |
$9.26
|
| Rate for Payer: First Health Commercial |
$10.60
|
| Rate for Payer: Humana Commercial |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.82
|
| Rate for Payer: Ohio Health Group HMO |
$8.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.46
|
| Rate for Payer: PHCS Commercial |
$10.71
|
| Rate for Payer: United Healthcare All Payer |
$9.82
|
|
|
INSTANT PORE REFINER 29 G GBL
|
Professional
|
Both
|
$60.00
|
|
| Hospital Charge Code |
22200145
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$21.00 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$60.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
|
|
INSTESTINAL STRICTUROPLASTY
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
76101858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$597.17 |
| Max. Negotiated Rate |
$2,250.00 |
| Rate for Payer: Aetna Commercial |
$1,556.12
|
| Rate for Payer: Anthem Medicaid |
$597.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,250.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,444.55
|
| Rate for Payer: Healthspan PPO |
$1,312.31
|
| Rate for Payer: Humana Medicaid |
$597.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,376.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.11
|
| Rate for Payer: Molina Healthcare Passport |
$597.17
|
| Rate for Payer: Multiplan PHCS |
$1,350.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,575.00
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.14
|
|
|
INSTESTINAL STRICTUROPLASTY
|
Facility
|
OP
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
76101858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem Medicaid |
$773.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,867.50
|
| Rate for Payer: First Health Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial |
$1,912.50
|
| Rate for Payer: Humana KY Medicaid |
$773.78
|
| Rate for Payer: Kentucky WC Medicaid |
$781.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,845.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,660.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$789.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,980.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$292.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$697.50
|
| Rate for Payer: PHCS Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare All Payer |
$1,980.00
|
|
|
INSTESTINAL STRICTUROPLASTY
|
Facility
|
IP
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
76101858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$2,160.00 |
| Rate for Payer: Aetna Commercial |
$1,732.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,755.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,867.50
|
| Rate for Payer: First Health Commercial |
$2,137.50
|
| Rate for Payer: Humana Commercial |
$1,912.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,845.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,660.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$675.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,980.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$292.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$697.50
|
| Rate for Payer: PHCS Commercial |
$2,160.00
|
| Rate for Payer: United Healthcare All Payer |
$1,980.00
|
|
|
INSTESTINAL STRICTUROPLASTY(P
|
Professional
|
Both
|
$2,250.00
|
|
|
Service Code
|
HCPCS 44615
|
| Hospital Charge Code |
761P1858
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$597.17 |
| Max. Negotiated Rate |
$2,250.00 |
| Rate for Payer: Aetna Commercial |
$1,556.12
|
| Rate for Payer: Anthem Medicaid |
$597.17
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,250.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cash Price |
$1,125.00
|
| Rate for Payer: Cigna Commercial |
$1,444.55
|
| Rate for Payer: Healthspan PPO |
$1,312.31
|
| Rate for Payer: Humana Medicaid |
$597.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,376.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$609.11
|
| Rate for Payer: Molina Healthcare Passport |
$597.17
|
| Rate for Payer: Multiplan PHCS |
$1,350.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,575.00
|
| Rate for Payer: UHCCP Medicaid |
$787.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$603.14
|
|
|
INST LEADLSS PACER SING CHAM
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 0823T
|
| Hospital Charge Code |
76102948
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
INST LEADLSS PACER SING CHAM
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 0823T
|
| Hospital Charge Code |
76102948
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$23,589.87 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,849.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,589.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,747.38
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$16,849.91
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,219.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
INST LEADLSS PACER SING CHAM
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 0823T
|
| Hospital Charge Code |
76102948
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.00 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
|
|
INSULIN LEVEL TOTAL
|
Facility
|
OP
|
$117.03
|
|
|
Service Code
|
HCPCS 83525
|
| Hospital Charge Code |
30000430
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$112.35 |
| Rate for Payer: Aetna Commercial |
$90.11
|
| Rate for Payer: Anthem Medicaid |
$11.43
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$11.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.43
|
| Rate for Payer: Cash Price |
$58.52
|
| Rate for Payer: Cash Price |
$58.52
|
| Rate for Payer: Cigna Commercial |
$97.13
|
| Rate for Payer: First Health Commercial |
$111.18
|
| Rate for Payer: Humana Commercial |
$99.48
|
| Rate for Payer: Humana KY Medicaid |
$11.43
|
| Rate for Payer: Humana Medicare Advantage |
$11.43
|
| Rate for Payer: Kentucky WC Medicaid |
$11.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.99
|
| Rate for Payer: Ohio Health Group HMO |
$87.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.28
|
| Rate for Payer: PHCS Commercial |
$112.35
|
| Rate for Payer: United Healthcare All Payer |
$102.99
|
|
|
INSULIN LEVEL TOTAL
|
Facility
|
IP
|
$117.03
|
|
|
Service Code
|
HCPCS 83525
|
| Hospital Charge Code |
30000430
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.21 |
| Max. Negotiated Rate |
$112.35 |
| Rate for Payer: Aetna Commercial |
$90.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.98
|
| Rate for Payer: Cash Price |
$58.52
|
| Rate for Payer: Cigna Commercial |
$97.13
|
| Rate for Payer: First Health Commercial |
$111.18
|
| Rate for Payer: Humana Commercial |
$99.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.99
|
| Rate for Payer: Ohio Health Group HMO |
$87.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.28
|
| Rate for Payer: PHCS Commercial |
$112.35
|
| Rate for Payer: United Healthcare All Payer |
$102.99
|
|
|
INSULIN-TPN INJECTION IV(EA 5U
|
Facility
|
IP
|
$63.24
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$60.71 |
| Rate for Payer: Aetna Commercial |
$48.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.33
|
| Rate for Payer: Cash Price |
$31.62
|
| Rate for Payer: Cigna Commercial |
$52.49
|
| Rate for Payer: First Health Commercial |
$60.08
|
| Rate for Payer: Humana Commercial |
$53.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.65
|
| Rate for Payer: Ohio Health Group HMO |
$47.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.60
|
| Rate for Payer: PHCS Commercial |
$60.71
|
| Rate for Payer: United Healthcare All Payer |
$55.65
|
|
|
INSULIN-TPN INJECTION IV(EA 5U
|
Facility
|
OP
|
$63.24
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
25002182
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$60.71 |
| Rate for Payer: Aetna Commercial |
$48.69
|
| Rate for Payer: Anthem Medicaid |
$21.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$49.33
|
| Rate for Payer: Cash Price |
$31.62
|
| Rate for Payer: Cigna Commercial |
$52.49
|
| Rate for Payer: First Health Commercial |
$60.08
|
| Rate for Payer: Humana Commercial |
$53.75
|
| Rate for Payer: Humana KY Medicaid |
$21.75
|
| Rate for Payer: Kentucky WC Medicaid |
$21.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$51.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$46.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$55.65
|
| Rate for Payer: Ohio Health Group HMO |
$47.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.60
|
| Rate for Payer: PHCS Commercial |
$60.71
|
| Rate for Payer: United Healthcare All Payer |
$55.65
|
|
