|
JETSTREAM XC 2.1/3.0 PV31300
|
Facility
|
IP
|
$15,720.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,043.60 |
| Max. Negotiated Rate |
$15,091.20 |
| Rate for Payer: Aetna Commercial |
$12,104.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,261.60
|
| Rate for Payer: Cash Price |
$7,860.00
|
| Rate for Payer: Cigna Commercial |
$13,047.60
|
| Rate for Payer: First Health Commercial |
$14,934.00
|
| Rate for Payer: Humana Commercial |
$13,362.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,890.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,601.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,833.60
|
| Rate for Payer: Ohio Health Group HMO |
$11,790.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,043.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,873.20
|
| Rate for Payer: PHCS Commercial |
$15,091.20
|
| Rate for Payer: United Healthcare All Payer |
$13,833.60
|
|
|
JETSTREAM XC 2.1/3.0 PV31300
|
Facility
|
OP
|
$15,720.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,043.60 |
| Max. Negotiated Rate |
$15,091.20 |
| Rate for Payer: Aetna Commercial |
$12,104.40
|
| Rate for Payer: Anthem Medicaid |
$5,406.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,261.60
|
| Rate for Payer: Cash Price |
$7,860.00
|
| Rate for Payer: Cigna Commercial |
$13,047.60
|
| Rate for Payer: First Health Commercial |
$14,934.00
|
| Rate for Payer: Humana Commercial |
$13,362.00
|
| Rate for Payer: Humana KY Medicaid |
$5,406.11
|
| Rate for Payer: Kentucky WC Medicaid |
$5,461.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,890.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,601.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,514.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,833.60
|
| Rate for Payer: Ohio Health Group HMO |
$11,790.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,043.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,873.20
|
| Rate for Payer: PHCS Commercial |
$15,091.20
|
| Rate for Payer: United Healthcare All Payer |
$13,833.60
|
|
|
JETSTREAM XC 2.4/3.4 PV41340
|
Facility
|
OP
|
$15,720.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,043.60 |
| Max. Negotiated Rate |
$15,091.20 |
| Rate for Payer: Aetna Commercial |
$12,104.40
|
| Rate for Payer: Anthem Medicaid |
$5,406.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,261.60
|
| Rate for Payer: Cash Price |
$7,860.00
|
| Rate for Payer: Cigna Commercial |
$13,047.60
|
| Rate for Payer: First Health Commercial |
$14,934.00
|
| Rate for Payer: Humana Commercial |
$13,362.00
|
| Rate for Payer: Humana KY Medicaid |
$5,406.11
|
| Rate for Payer: Kentucky WC Medicaid |
$5,461.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,890.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,601.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,514.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,833.60
|
| Rate for Payer: Ohio Health Group HMO |
$11,790.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,043.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,873.20
|
| Rate for Payer: PHCS Commercial |
$15,091.20
|
| Rate for Payer: United Healthcare All Payer |
$13,833.60
|
|
|
JETSTREAM XC 2.4/3.4 PV41340
|
Facility
|
IP
|
$15,720.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,043.60 |
| Max. Negotiated Rate |
$15,091.20 |
| Rate for Payer: Aetna Commercial |
$12,104.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,261.60
|
| Rate for Payer: Cash Price |
$7,860.00
|
| Rate for Payer: Cigna Commercial |
$13,047.60
|
| Rate for Payer: First Health Commercial |
$14,934.00
|
| Rate for Payer: Humana Commercial |
$13,362.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,890.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,601.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,833.60
|
| Rate for Payer: Ohio Health Group HMO |
$11,790.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,144.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,043.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,873.20
|
| Rate for Payer: PHCS Commercial |
$15,091.20
|
| Rate for Payer: United Healthcare All Payer |
$13,833.60
|
|
|
JEVITY 1.5 CAL LIQUID
|
Facility
|
IP
|
$71.63
|
|
|
Service Code
|
NDC 70074062682
|
| Hospital Charge Code |
25003140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$68.76 |
| Rate for Payer: Aetna Commercial |
$55.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.87
|
| Rate for Payer: Cash Price |
$35.81
|
| Rate for Payer: Cigna Commercial |
$59.45
|
| Rate for Payer: First Health Commercial |
$68.05
|
| Rate for Payer: Humana Commercial |
$60.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.03
|
| Rate for Payer: Ohio Health Group HMO |
$53.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.21
|
| Rate for Payer: PHCS Commercial |
$68.76
|
| Rate for Payer: United Healthcare All Payer |
$63.03
|
|
|
JEVITY 1.5 CAL LIQUID
|
Facility
|
OP
|
$71.63
|
|
|
Service Code
|
NDC 70074062682
|
| Hospital Charge Code |
25003140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.31 |
| Max. Negotiated Rate |
$68.76 |
| Rate for Payer: Aetna Commercial |
$55.16
|
| Rate for Payer: Anthem Medicaid |
$24.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.87
|
| Rate for Payer: Cash Price |
$35.81
|
| Rate for Payer: Cigna Commercial |
$59.45
|
| Rate for Payer: First Health Commercial |
$68.05
|
| Rate for Payer: Humana Commercial |
$60.89
|
| Rate for Payer: Humana KY Medicaid |
$24.63
|
| Rate for Payer: Kentucky WC Medicaid |
$24.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$25.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.03
|
| Rate for Payer: Ohio Health Group HMO |
$53.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.21
|
| Rate for Payer: PHCS Commercial |
$68.76
|
| Rate for Payer: United Healthcare All Payer |
$63.03
|
|
|
JEVITY PLUS
|
Facility
|
OP
|
$91.19
|
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$87.54 |
| Rate for Payer: Aetna Commercial |
$70.22
|
| Rate for Payer: Anthem Medicaid |
$31.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.13
|
| Rate for Payer: Cash Price |
$45.59
|
| Rate for Payer: Cigna Commercial |
$75.69
|
| Rate for Payer: First Health Commercial |
$86.63
|
| Rate for Payer: Humana Commercial |
$77.51
|
| Rate for Payer: Humana KY Medicaid |
$31.36
|
| Rate for Payer: Kentucky WC Medicaid |
$31.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.25
|
| Rate for Payer: Ohio Health Group HMO |
$68.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.27
|
| Rate for Payer: PHCS Commercial |
$87.54
|
| Rate for Payer: United Healthcare All Payer |
$80.25
|
|
|
JEVITY PLUS
|
Facility
|
IP
|
$91.19
|
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$87.54 |
| Rate for Payer: Aetna Commercial |
$70.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$71.13
|
| Rate for Payer: Cash Price |
$45.59
|
| Rate for Payer: Cigna Commercial |
$75.69
|
| Rate for Payer: First Health Commercial |
$86.63
|
| Rate for Payer: Humana Commercial |
$77.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.25
|
| Rate for Payer: Ohio Health Group HMO |
$68.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.27
|
| Rate for Payer: PHCS Commercial |
$87.54
|
| Rate for Payer: United Healthcare All Payer |
$80.25
|
|
|
JEVITY PLUS
|
Facility
|
IP
|
$71.12
|
|
|
Service Code
|
NDC 70074062684
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$68.28 |
| Rate for Payer: Aetna Commercial |
$54.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.47
|
| Rate for Payer: Cash Price |
$35.56
|
| Rate for Payer: Cigna Commercial |
$59.03
|
| Rate for Payer: First Health Commercial |
$67.56
|
| Rate for Payer: Humana Commercial |
$60.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.59
|
| Rate for Payer: Ohio Health Group HMO |
$53.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.05
|
| Rate for Payer: PHCS Commercial |
$68.28
|
| Rate for Payer: United Healthcare All Payer |
$62.59
|
|
|
JEVITY PLUS
|
Facility
|
OP
|
$71.12
|
|
|
Service Code
|
NDC 70074062684
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.25 |
| Max. Negotiated Rate |
$68.28 |
| Rate for Payer: Aetna Commercial |
$54.76
|
| Rate for Payer: Anthem Medicaid |
$24.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.47
|
| Rate for Payer: Cash Price |
$35.56
|
| Rate for Payer: Cigna Commercial |
$59.03
|
| Rate for Payer: First Health Commercial |
$67.56
|
| Rate for Payer: Humana Commercial |
$60.45
|
| Rate for Payer: Humana KY Medicaid |
$24.46
|
| Rate for Payer: Kentucky WC Medicaid |
$24.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$58.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$24.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$62.59
|
| Rate for Payer: Ohio Health Group HMO |
$53.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.05
|
| Rate for Payer: PHCS Commercial |
$68.28
|
| Rate for Payer: United Healthcare All Payer |
$62.59
|
|
|
JEVITY (TF) 240ML
|
Facility
|
IP
|
$65.26
|
|
|
Service Code
|
NDC 70074053119
|
| Hospital Charge Code |
25003139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$62.65 |
| Rate for Payer: Aetna Commercial |
$50.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.90
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cigna Commercial |
$54.17
|
| Rate for Payer: First Health Commercial |
$62.00
|
| Rate for Payer: Humana Commercial |
$55.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.43
|
| Rate for Payer: Ohio Health Group HMO |
$48.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.23
|
| Rate for Payer: PHCS Commercial |
$62.65
|
| Rate for Payer: United Healthcare All Payer |
$57.43
|
|
|
JEVITY (TF) 240ML
|
Facility
|
OP
|
$65.26
|
|
|
Service Code
|
NDC 70074053119
|
| Hospital Charge Code |
25003139
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.48 |
| Max. Negotiated Rate |
$62.65 |
| Rate for Payer: Aetna Commercial |
$50.25
|
| Rate for Payer: Anthem Medicaid |
$22.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.90
|
| Rate for Payer: Cash Price |
$32.63
|
| Rate for Payer: Cigna Commercial |
$54.17
|
| Rate for Payer: First Health Commercial |
$62.00
|
| Rate for Payer: Humana Commercial |
$55.47
|
| Rate for Payer: Humana KY Medicaid |
$22.44
|
| Rate for Payer: Kentucky WC Medicaid |
$22.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.43
|
| Rate for Payer: Ohio Health Group HMO |
$48.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.23
|
| Rate for Payer: PHCS Commercial |
$62.65
|
| Rate for Payer: United Healthcare All Payer |
$57.43
|
|
|
JEVTANA 1MG (60MG VIAL)
|
Facility
|
OP
|
$75,586.87
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
25002572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.45 |
| Max. Negotiated Rate |
$72,563.40 |
| Rate for Payer: Aetna Commercial |
$58,201.89
|
| Rate for Payer: Anthem Medicaid |
$25,994.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$210.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,957.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$294.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$284.11
|
| Rate for Payer: Cash Price |
$37,793.43
|
| Rate for Payer: Cash Price |
$37,793.43
|
| Rate for Payer: Cigna Commercial |
$62,737.10
|
| Rate for Payer: First Health Commercial |
$71,807.53
|
| Rate for Payer: Humana Commercial |
$64,248.84
|
| Rate for Payer: Humana KY Medicaid |
$25,994.32
|
| Rate for Payer: Humana Medicare Advantage |
$210.45
|
| Rate for Payer: Kentucky WC Medicaid |
$26,258.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,981.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,783.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,515.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,516.45
|
| Rate for Payer: Ohio Health Group HMO |
$56,690.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,117.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,826.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,431.93
|
| Rate for Payer: PHCS Commercial |
$72,563.40
|
| Rate for Payer: United Healthcare All Payer |
$66,516.45
|
|
|
JEVTANA 1MG (60MG VIAL)
|
Facility
|
IP
|
$75,586.87
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
25002572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9,826.29 |
| Max. Negotiated Rate |
$72,563.40 |
| Rate for Payer: Aetna Commercial |
$58,201.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,957.76
|
| Rate for Payer: Cash Price |
$37,793.43
|
| Rate for Payer: Cigna Commercial |
$62,737.10
|
| Rate for Payer: First Health Commercial |
$71,807.53
|
| Rate for Payer: Humana Commercial |
$64,248.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,981.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,783.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,676.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,516.45
|
| Rate for Payer: Ohio Health Group HMO |
$56,690.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,117.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,826.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,431.93
|
| Rate for Payer: PHCS Commercial |
$72,563.40
|
| Rate for Payer: United Healthcare All Payer |
$66,516.45
|
|
|
JL 3.5 CATH 5F
|
Facility
|
OP
|
$164.07
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$157.51 |
| Rate for Payer: Aetna Commercial |
$126.33
|
| Rate for Payer: Anthem Medicaid |
$56.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.97
|
| Rate for Payer: Cash Price |
$82.03
|
| Rate for Payer: Cigna Commercial |
$136.18
|
| Rate for Payer: First Health Commercial |
$155.87
|
| Rate for Payer: Humana Commercial |
$139.46
|
| Rate for Payer: Humana KY Medicaid |
$56.42
|
| Rate for Payer: Kentucky WC Medicaid |
$57.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.38
|
| Rate for Payer: Ohio Health Group HMO |
$123.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.86
|
| Rate for Payer: PHCS Commercial |
$157.51
|
| Rate for Payer: United Healthcare All Payer |
$144.38
|
|
|
JL 3.5 CATH 5F
|
Facility
|
IP
|
$164.07
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$157.51 |
| Rate for Payer: Aetna Commercial |
$126.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.97
|
| Rate for Payer: Cash Price |
$82.03
|
| Rate for Payer: Cigna Commercial |
$136.18
|
| Rate for Payer: First Health Commercial |
$155.87
|
| Rate for Payer: Humana Commercial |
$139.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.38
|
| Rate for Payer: Ohio Health Group HMO |
$123.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.86
|
| Rate for Payer: PHCS Commercial |
$157.51
|
| Rate for Payer: United Healthcare All Payer |
$144.38
|
|
|
JL3.5 LEFT CORN 6F
|
Facility
|
OP
|
$159.98
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.58 |
| Rate for Payer: Humana Commercial |
$135.98
|
| Rate for Payer: Humana KY Medicaid |
$55.02
|
| Rate for Payer: Kentucky WC Medicaid |
$55.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$56.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.78
|
| Rate for Payer: Ohio Health Group HMO |
$119.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.59
|
| Rate for Payer: PHCS Commercial |
$153.58
|
| Rate for Payer: United Healthcare All Payer |
$140.78
|
| Rate for Payer: Aetna Commercial |
$123.18
|
| Rate for Payer: Anthem Medicaid |
$55.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.78
|
| Rate for Payer: Cash Price |
$79.99
|
| Rate for Payer: Cigna Commercial |
$132.78
|
| Rate for Payer: First Health Commercial |
$151.98
|
|
|
JL3.5 LEFT CORN 6F
|
Facility
|
IP
|
$159.98
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$153.58 |
| Rate for Payer: Aetna Commercial |
$123.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$124.78
|
| Rate for Payer: Cash Price |
$79.99
|
| Rate for Payer: Cigna Commercial |
$132.78
|
| Rate for Payer: First Health Commercial |
$151.98
|
| Rate for Payer: Humana Commercial |
$135.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$131.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$118.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$140.78
|
| Rate for Payer: Ohio Health Group HMO |
$119.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.59
|
| Rate for Payer: PHCS Commercial |
$153.58
|
| Rate for Payer: United Healthcare All Payer |
$140.78
|
|
|
JL3 GUIDE 6F
|
Facility
|
IP
|
$775.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna Commercial |
$597.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.89
|
| Rate for Payer: Cash Price |
$387.75
|
| Rate for Payer: Cigna Commercial |
$643.66
|
| Rate for Payer: First Health Commercial |
$736.72
|
| Rate for Payer: Humana Commercial |
$659.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.44
|
| Rate for Payer: Ohio Health Group HMO |
$581.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.40
|
| Rate for Payer: PHCS Commercial |
$744.48
|
| Rate for Payer: United Healthcare All Payer |
$682.44
|
|
|
JL3 GUIDE 6F
|
Facility
|
OP
|
$775.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna Commercial |
$597.14
|
| Rate for Payer: Anthem Medicaid |
$266.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.89
|
| Rate for Payer: Cash Price |
$387.75
|
| Rate for Payer: Cigna Commercial |
$643.66
|
| Rate for Payer: First Health Commercial |
$736.72
|
| Rate for Payer: Humana Commercial |
$659.18
|
| Rate for Payer: Humana KY Medicaid |
$266.69
|
| Rate for Payer: Kentucky WC Medicaid |
$269.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$272.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.44
|
| Rate for Payer: Ohio Health Group HMO |
$581.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.40
|
| Rate for Payer: PHCS Commercial |
$744.48
|
| Rate for Payer: United Healthcare All Payer |
$682.44
|
|
|
JL3 GUIDE CATH 5F
|
Facility
|
IP
|
$775.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna Commercial |
$597.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.89
|
| Rate for Payer: Cash Price |
$387.75
|
| Rate for Payer: Cigna Commercial |
$643.66
|
| Rate for Payer: First Health Commercial |
$736.72
|
| Rate for Payer: Humana Commercial |
$659.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.44
|
| Rate for Payer: Ohio Health Group HMO |
$581.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.40
|
| Rate for Payer: PHCS Commercial |
$744.48
|
| Rate for Payer: United Healthcare All Payer |
$682.44
|
|
|
JL3 GUIDE CATH 5F
|
Facility
|
OP
|
$775.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna Commercial |
$597.14
|
| Rate for Payer: Anthem Medicaid |
$266.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.89
|
| Rate for Payer: Cash Price |
$387.75
|
| Rate for Payer: Cigna Commercial |
$643.66
|
| Rate for Payer: First Health Commercial |
$736.72
|
| Rate for Payer: Humana Commercial |
$659.18
|
| Rate for Payer: Humana KY Medicaid |
$266.69
|
| Rate for Payer: Kentucky WC Medicaid |
$269.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$272.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.44
|
| Rate for Payer: Ohio Health Group HMO |
$581.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.40
|
| Rate for Payer: PHCS Commercial |
$744.48
|
| Rate for Payer: United Healthcare All Payer |
$682.44
|
|
|
JL 4.5 6F 100CM
|
Facility
|
OP
|
$164.70
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Aetna Commercial |
$126.82
|
| Rate for Payer: Aetna Commercial |
$628.32
|
| Rate for Payer: Anthem Medicaid |
$56.64
|
| Rate for Payer: Anthem Medicaid |
$280.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cigna Commercial |
$677.28
|
| Rate for Payer: Cigna Commercial |
$136.70
|
| Rate for Payer: First Health Commercial |
$775.20
|
| Rate for Payer: First Health Commercial |
$156.46
|
| Rate for Payer: Humana Commercial |
$140.00
|
| Rate for Payer: Humana Commercial |
$693.60
|
| Rate for Payer: Humana KY Medicaid |
$56.64
|
| Rate for Payer: Humana KY Medicaid |
$280.62
|
| Rate for Payer: Kentucky WC Medicaid |
$283.48
|
| Rate for Payer: Kentucky WC Medicaid |
$57.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$669.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$602.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$286.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$718.08
|
| Rate for Payer: Ohio Health Group HMO |
$123.52
|
| Rate for Payer: Ohio Health Group HMO |
$612.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.96
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: PHCS Commercial |
$158.11
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
| Rate for Payer: United Healthcare All Payer |
$144.94
|
|
|
JL 4.5 6F 100CM
|
Facility
|
IP
|
$164.70
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$158.11 |
| Rate for Payer: Aetna Commercial |
$126.82
|
| Rate for Payer: Aetna Commercial |
$628.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Cash Price |
$82.35
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cigna Commercial |
$136.70
|
| Rate for Payer: Cigna Commercial |
$677.28
|
| Rate for Payer: First Health Commercial |
$775.20
|
| Rate for Payer: First Health Commercial |
$156.46
|
| Rate for Payer: Humana Commercial |
$693.60
|
| Rate for Payer: Humana Commercial |
$140.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$135.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$669.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$602.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$718.08
|
| Rate for Payer: Ohio Health Group HMO |
$123.52
|
| Rate for Payer: Ohio Health Group HMO |
$612.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.06
|
| Rate for Payer: PHCS Commercial |
$158.11
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: United Healthcare All Payer |
$144.94
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
|
|
JL 4.5 CATH 5F
|
Facility
|
OP
|
$164.07
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.33 |
| Max. Negotiated Rate |
$157.51 |
| Rate for Payer: Aetna Commercial |
$126.33
|
| Rate for Payer: Anthem Medicaid |
$56.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.97
|
| Rate for Payer: Cash Price |
$82.03
|
| Rate for Payer: Cigna Commercial |
$136.18
|
| Rate for Payer: First Health Commercial |
$155.87
|
| Rate for Payer: Humana Commercial |
$139.46
|
| Rate for Payer: Humana KY Medicaid |
$56.42
|
| Rate for Payer: Kentucky WC Medicaid |
$57.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.38
|
| Rate for Payer: Ohio Health Group HMO |
$123.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.86
|
| Rate for Payer: PHCS Commercial |
$157.51
|
| Rate for Payer: United Healthcare All Payer |
$144.38
|
|
