|
JETSTREAM SC 1.65
|
Facility
|
OP
|
$16,573.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,971.90 |
| Max. Negotiated Rate |
$15,910.08 |
| Rate for Payer: Aetna Commercial |
$12,761.21
|
| Rate for Payer: Anthem Medicaid |
$5,699.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,926.94
|
| Rate for Payer: Cash Price |
$8,286.50
|
| Rate for Payer: Cigna Commercial |
$13,755.59
|
| Rate for Payer: First Health Commercial |
$15,744.35
|
| Rate for Payer: Humana Commercial |
$14,087.05
|
| Rate for Payer: Humana KY Medicaid |
$5,699.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,757.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,589.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,230.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,971.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,813.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,584.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,429.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,258.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,418.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,435.37
|
| Rate for Payer: PHCS Commercial |
$15,910.08
|
| Rate for Payer: United Healthcare All Payer |
$14,584.24
|
|
|
JETSTREAM SC 1.65
|
Facility
|
IP
|
$16,573.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,971.90 |
| Max. Negotiated Rate |
$15,910.08 |
| Rate for Payer: Aetna Commercial |
$12,761.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,926.94
|
| Rate for Payer: Cash Price |
$8,286.50
|
| Rate for Payer: Cigna Commercial |
$13,755.59
|
| Rate for Payer: First Health Commercial |
$15,744.35
|
| Rate for Payer: Humana Commercial |
$14,087.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,589.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,230.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,971.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,584.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,429.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,258.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,418.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,435.37
|
| Rate for Payer: PHCS Commercial |
$15,910.08
|
| Rate for Payer: United Healthcare All Payer |
$14,584.24
|
|
|
JETSTREAM XC 2.1/3.0 PV31300
|
Facility
|
OP
|
$16,240.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.00 |
| Max. Negotiated Rate |
$15,590.40 |
| Rate for Payer: Aetna Commercial |
$12,504.80
|
| Rate for Payer: Anthem Medicaid |
$5,584.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,667.20
|
| Rate for Payer: Cash Price |
$8,120.00
|
| Rate for Payer: Cigna Commercial |
$13,479.20
|
| Rate for Payer: First Health Commercial |
$15,428.00
|
| Rate for Payer: Humana Commercial |
$13,804.00
|
| Rate for Payer: Humana KY Medicaid |
$5,584.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,641.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,316.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,985.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,872.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,696.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,291.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,128.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,205.60
|
| Rate for Payer: PHCS Commercial |
$15,590.40
|
| Rate for Payer: United Healthcare All Payer |
$14,291.20
|
|
|
JETSTREAM XC 2.1/3.0 PV31300
|
Facility
|
IP
|
$16,240.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.00 |
| Max. Negotiated Rate |
$15,590.40 |
| Rate for Payer: Aetna Commercial |
$12,504.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,667.20
|
| Rate for Payer: Cash Price |
$8,120.00
|
| Rate for Payer: Cigna Commercial |
$13,479.20
|
| Rate for Payer: First Health Commercial |
$15,428.00
|
| Rate for Payer: Humana Commercial |
$13,804.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,316.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,985.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,872.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,291.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,128.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,205.60
|
| Rate for Payer: PHCS Commercial |
$15,590.40
|
| Rate for Payer: United Healthcare All Payer |
$14,291.20
|
|
|
JETSTREAM XC 2.4/3.4 PV41340
|
Facility
|
OP
|
$16,240.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.00 |
| Max. Negotiated Rate |
$15,590.40 |
| Rate for Payer: Aetna Commercial |
$12,504.80
|
| Rate for Payer: Anthem Medicaid |
$5,584.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,667.20
|
| Rate for Payer: Cash Price |
$8,120.00
|
| Rate for Payer: Cigna Commercial |
$13,479.20
|
| Rate for Payer: First Health Commercial |
$15,428.00
|
| Rate for Payer: Humana Commercial |
$13,804.00
|
| Rate for Payer: Humana KY Medicaid |
$5,584.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,641.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,316.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,985.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,872.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,696.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,291.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,128.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,205.60
|
| Rate for Payer: PHCS Commercial |
$15,590.40
|
| Rate for Payer: United Healthcare All Payer |
$14,291.20
|
|
|
JETSTREAM XC 2.4/3.4 PV41340
|
Facility
|
IP
|
$16,240.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.00 |
| Max. Negotiated Rate |
$15,590.40 |
| Rate for Payer: Aetna Commercial |
$12,504.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,667.20
|
| Rate for Payer: Cash Price |
$8,120.00
|
| Rate for Payer: Cigna Commercial |
$13,479.20
|
| Rate for Payer: First Health Commercial |
$15,428.00
|
| Rate for Payer: Humana Commercial |
$13,804.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,316.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,985.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,872.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,291.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,128.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,205.60
|
| Rate for Payer: PHCS Commercial |
$15,590.40
|
| Rate for Payer: United Healthcare All Payer |
$14,291.20
|
|
|
JEVITY 1.5 CAL LIQUID
|
Facility
|
IP
|
$71.63
|
|
|
Service Code
|
NDC 70074062682
|
| Hospital Charge Code |
25003140
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.49 |
| 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 |
$57.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.42
|
| 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 |
$21.49 |
| 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 |
$57.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.42
|
| Rate for Payer: PHCS Commercial |
$68.76
|
| Rate for Payer: United Healthcare All Payer |
$63.03
|
|
|
JEVITY PLUS
|
Facility
|
IP
|
$91.19
|
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.36 |
| 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 |
$72.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.92
|
| Rate for Payer: PHCS Commercial |
$87.54
|
| Rate for Payer: United Healthcare All Payer |
$80.25
|
|
|
JEVITY PLUS
|
Facility
|
OP
|
$71.12
|
|
|
Service Code
|
NDC 70074062684
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$21.34 |
| 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 |
$56.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.07
|
| Rate for Payer: PHCS Commercial |
$68.28
|
| Rate for Payer: United Healthcare All Payer |
$62.59
|
|
|
JEVITY PLUS
|
Facility
|
OP
|
$91.19
|
|
| Hospital Charge Code |
27000093
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.36 |
| 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 |
$72.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.92
|
| 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 |
$21.34 |
| 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 |
$56.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.07
|
| 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 |
$19.58 |
| 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 |
$48.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.03
|
| 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 |
$19.58 |
| 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 |
$48.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.03
|
| Rate for Payer: PHCS Commercial |
$62.65
|
| Rate for Payer: United Healthcare All Payer |
$57.43
|
|
|
JEVTANA 1MG (60MG VIAL)
|
Facility
|
IP
|
$78,255.08
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
25002572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23,476.52 |
| Max. Negotiated Rate |
$75,124.88 |
| Rate for Payer: Aetna Commercial |
$60,256.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61,038.96
|
| Rate for Payer: Cash Price |
$39,127.54
|
| Rate for Payer: Cigna Commercial |
$64,951.72
|
| Rate for Payer: First Health Commercial |
$74,342.33
|
| Rate for Payer: Humana Commercial |
$66,516.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64,169.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57,752.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,476.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$68,864.47
|
| Rate for Payer: Ohio Health Group HMO |
$58,691.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62,604.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68,081.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53,996.01
|
| Rate for Payer: PHCS Commercial |
$75,124.88
|
| Rate for Payer: United Healthcare All Payer |
$68,864.47
|
|
|
JEVTANA 1MG (60MG VIAL)
|
Facility
|
OP
|
$78,255.08
|
|
|
Service Code
|
HCPCS J9043
|
| Hospital Charge Code |
25002572
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.10 |
| Max. Negotiated Rate |
$75,124.88 |
| Rate for Payer: Aetna Commercial |
$60,256.41
|
| Rate for Payer: Anthem Medicaid |
$26,911.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$227.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61,038.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$317.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$306.58
|
| Rate for Payer: Cash Price |
$39,127.54
|
| Rate for Payer: Cash Price |
$39,127.54
|
| Rate for Payer: Cigna Commercial |
$64,951.72
|
| Rate for Payer: First Health Commercial |
$74,342.33
|
| Rate for Payer: Humana Commercial |
$66,516.82
|
| Rate for Payer: Humana KY Medicaid |
$26,911.92
|
| Rate for Payer: Humana Medicare Advantage |
$227.10
|
| Rate for Payer: Kentucky WC Medicaid |
$27,185.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64,169.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57,752.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$272.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$27,451.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$68,864.47
|
| Rate for Payer: Ohio Health Group HMO |
$58,691.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$62,604.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68,081.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53,996.01
|
| Rate for Payer: PHCS Commercial |
$75,124.88
|
| Rate for Payer: United Healthcare All Payer |
$68,864.47
|
|
|
JL 3.5 CATH 5F
|
Facility
|
IP
|
$440.10
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$422.50 |
| Rate for Payer: Aetna Commercial |
$338.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.28
|
| Rate for Payer: Cash Price |
$220.05
|
| Rate for Payer: Cigna Commercial |
$365.28
|
| Rate for Payer: First Health Commercial |
$418.10
|
| Rate for Payer: Humana Commercial |
$374.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$360.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.29
|
| Rate for Payer: Ohio Health Group HMO |
$330.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.67
|
| Rate for Payer: PHCS Commercial |
$422.50
|
| Rate for Payer: United Healthcare All Payer |
$387.29
|
|
|
JL 3.5 CATH 5F
|
Facility
|
OP
|
$440.10
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.03 |
| Max. Negotiated Rate |
$422.50 |
| Rate for Payer: Aetna Commercial |
$338.88
|
| Rate for Payer: Anthem Medicaid |
$151.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.28
|
| Rate for Payer: Cash Price |
$220.05
|
| Rate for Payer: Cigna Commercial |
$365.28
|
| Rate for Payer: First Health Commercial |
$418.10
|
| Rate for Payer: Humana Commercial |
$374.08
|
| Rate for Payer: Humana KY Medicaid |
$151.35
|
| Rate for Payer: Kentucky WC Medicaid |
$152.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$360.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$154.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.29
|
| Rate for Payer: Ohio Health Group HMO |
$330.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$382.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.67
|
| Rate for Payer: PHCS Commercial |
$422.50
|
| Rate for Payer: United Healthcare All Payer |
$387.29
|
|
|
JL3.5 LEFT CORN 6F
|
Facility
|
OP
|
$163.69
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.11 |
| Max. Negotiated Rate |
$157.14 |
| Rate for Payer: Aetna Commercial |
$126.04
|
| Rate for Payer: Anthem Medicaid |
$56.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Cash Price |
$81.84
|
| Rate for Payer: Cigna Commercial |
$135.86
|
| Rate for Payer: First Health Commercial |
$155.51
|
| Rate for Payer: Humana Commercial |
$139.14
|
| Rate for Payer: Humana KY Medicaid |
$56.29
|
| Rate for Payer: Kentucky WC Medicaid |
$56.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.05
|
| Rate for Payer: Ohio Health Group HMO |
$122.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.95
|
| Rate for Payer: PHCS Commercial |
$157.14
|
| Rate for Payer: United Healthcare All Payer |
$144.05
|
|
|
JL3.5 LEFT CORN 6F
|
Facility
|
IP
|
$163.69
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.11 |
| Max. Negotiated Rate |
$157.14 |
| Rate for Payer: Aetna Commercial |
$126.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.68
|
| Rate for Payer: Cash Price |
$81.84
|
| Rate for Payer: Cigna Commercial |
$135.86
|
| Rate for Payer: First Health Commercial |
$155.51
|
| Rate for Payer: Humana Commercial |
$139.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.05
|
| Rate for Payer: Ohio Health Group HMO |
$122.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.95
|
| Rate for Payer: PHCS Commercial |
$157.14
|
| Rate for Payer: United Healthcare All Payer |
$144.05
|
|
|
JL3 GUIDE 6F
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem Medicaid |
$273.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Humana KY Medicaid |
$273.40
|
| Rate for Payer: Kentucky WC Medicaid |
$276.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
JL3 GUIDE 6F
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
JL3 GUIDE CATH 5F
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem Medicaid |
$273.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Humana KY Medicaid |
$273.40
|
| Rate for Payer: Kentucky WC Medicaid |
$276.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
JL3 GUIDE CATH 5F
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
JL 4.5 6F 100CM
|
Facility
|
IP
|
$1,150.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$345.00 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$885.50
|
| Rate for Payer: Aetna Commercial |
$129.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.62
|
| Rate for Payer: Cash Price |
$575.00
|
| Rate for Payer: Cash Price |
$84.38
|
| Rate for Payer: Cigna Commercial |
$954.50
|
| Rate for Payer: Cigna Commercial |
$140.06
|
| Rate for Payer: First Health Commercial |
$160.31
|
| Rate for Payer: First Health Commercial |
$1,092.50
|
| Rate for Payer: Humana Commercial |
$143.44
|
| Rate for Payer: Humana Commercial |
$977.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$848.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.50
|
| Rate for Payer: Ohio Health Group HMO |
$862.50
|
| Rate for Payer: Ohio Health Group HMO |
$126.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$920.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,000.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$793.50
|
| Rate for Payer: PHCS Commercial |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Payer |
$1,012.00
|
| Rate for Payer: United Healthcare All Payer |
$148.50
|
|
