|
LATERALIZD HUM CUP DIA 36+ 9MM
|
Facility
|
OP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem Medicaid |
$2,771.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Humana KY Medicaid |
$2,771.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,799.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,827.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 9MM
|
Facility
|
IP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 42+ 3MM
|
Facility
|
OP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem Medicaid |
$2,613.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Humana KY Medicaid |
$2,613.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,639.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,665.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
LATERALIZD HUM CUP DIA 42+ 3MM
|
Facility
|
IP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
LATERALIZD HUM CUP DIA 42+ 6MM
|
Facility
|
IP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 42+ 6MM
|
Facility
|
OP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem Medicaid |
$2,771.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Humana KY Medicaid |
$2,771.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,799.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,827.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATERALIZD HUM CUP DIA 42+ 9MM
|
Facility
|
OP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem Medicaid |
$2,613.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Humana KY Medicaid |
$2,613.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,639.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,665.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
LATERALIZD HUM CUP DIA 42+ 9MM
|
Facility
|
IP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
LAT RETINACULAR RELEASE OPEN
|
Facility
|
IP
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
76100841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$645.00 |
| Max. Negotiated Rate |
$2,064.00 |
| Rate for Payer: Aetna Commercial |
$1,655.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$1,784.50
|
| Rate for Payer: First Health Commercial |
$2,042.50
|
| Rate for Payer: Humana Commercial |
$1,827.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,586.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$645.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,892.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,612.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,870.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,483.50
|
| Rate for Payer: PHCS Commercial |
$2,064.00
|
| Rate for Payer: United Healthcare All Payer |
$1,892.00
|
|
|
LAT RETINACULAR RELEASE OPEN
|
Facility
|
OP
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
76100841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$739.38 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$1,655.50
|
| Rate for Payer: Anthem Medicaid |
$739.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$1,784.50
|
| Rate for Payer: First Health Commercial |
$2,042.50
|
| Rate for Payer: Humana Commercial |
$1,827.50
|
| Rate for Payer: Humana KY Medicaid |
$739.38
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$746.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,586.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$754.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,892.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,612.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,870.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,483.50
|
| Rate for Payer: PHCS Commercial |
$2,064.00
|
| Rate for Payer: United Healthcare All Payer |
$1,892.00
|
|
|
LAT RETINACULAR RELEASE OPEN
|
Professional
|
Both
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
76100841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.40 |
| Max. Negotiated Rate |
$1,290.00 |
| Rate for Payer: Aetna Commercial |
$634.87
|
| Rate for Payer: Ambetter Exchange |
$435.06
|
| Rate for Payer: Anthem Medicaid |
$347.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$435.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$435.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$522.07
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$706.29
|
| Rate for Payer: Healthspan PPO |
$575.06
|
| Rate for Payer: Humana Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$545.40
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$435.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$435.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$354.35
|
| Rate for Payer: Molina Healthcare Passport |
$347.40
|
| Rate for Payer: Multiplan PHCS |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$565.58
|
| Rate for Payer: UHCCP Medicaid |
$752.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$350.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$435.06
|
|
|
LAT RETINACULAR RELEASE OPE(P
|
Professional
|
Both
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
761P0841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.40 |
| Max. Negotiated Rate |
$1,290.00 |
| Rate for Payer: Aetna Commercial |
$634.87
|
| Rate for Payer: Ambetter Exchange |
$435.06
|
| Rate for Payer: Anthem Medicaid |
$347.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$435.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$435.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$522.07
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$706.29
|
| Rate for Payer: Healthspan PPO |
$575.06
|
| Rate for Payer: Humana Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$545.40
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$435.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$435.06
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$354.35
|
| Rate for Payer: Molina Healthcare Passport |
$347.40
|
| Rate for Payer: Multiplan PHCS |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$565.58
|
| Rate for Payer: UHCCP Medicaid |
$752.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$350.87
|
| Rate for Payer: Wellcare Medicare Advantage |
$435.06
|
|
|
LAT RETN HUM CUP DIA 36+ 6MM
|
Facility
|
IP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
LAT RETN HUM CUP DIA 36+ 6MM
|
Facility
|
OP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem Medicaid |
$2,613.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Humana KY Medicaid |
$2,613.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,639.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,665.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
LAT RETN HUM CUP DIA 42+ 6MM
|
Facility
|
IP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LAT RETN HUM CUP DIA 42+ 6MM
|
Facility
|
OP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem Medicaid |
$2,771.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Humana KY Medicaid |
$2,771.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,799.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,827.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
|
LATUDA 120 MG TABLET
|
Facility
|
IP
|
$142.59
|
|
|
Service Code
|
NDC 63402031230
|
| Hospital Charge Code |
25004056
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.78 |
| Max. Negotiated Rate |
$136.89 |
| Rate for Payer: Aetna Commercial |
$109.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.22
|
| Rate for Payer: Cash Price |
$71.30
|
| Rate for Payer: Cigna Commercial |
$118.35
|
| Rate for Payer: First Health Commercial |
$135.46
|
| Rate for Payer: Humana Commercial |
$121.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.48
|
| Rate for Payer: Ohio Health Group HMO |
$106.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$114.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$98.39
|
| Rate for Payer: PHCS Commercial |
$136.89
|
| Rate for Payer: United Healthcare All Payer |
$125.48
|
|
|
LATUDA 120 MG TABLET
|
Facility
|
OP
|
$142.59
|
|
|
Service Code
|
NDC 63402031230
|
| Hospital Charge Code |
25004056
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.78 |
| Max. Negotiated Rate |
$136.89 |
| Rate for Payer: Aetna Commercial |
$109.79
|
| Rate for Payer: Anthem Medicaid |
$49.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.22
|
| Rate for Payer: Cash Price |
$71.30
|
| Rate for Payer: Cigna Commercial |
$118.35
|
| Rate for Payer: First Health Commercial |
$135.46
|
| Rate for Payer: Humana Commercial |
$121.20
|
| Rate for Payer: Humana KY Medicaid |
$49.04
|
| Rate for Payer: Kentucky WC Medicaid |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.48
|
| Rate for Payer: Ohio Health Group HMO |
$106.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$114.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$98.39
|
| Rate for Payer: PHCS Commercial |
$136.89
|
| Rate for Payer: United Healthcare All Payer |
$125.48
|
|
|
LATUDA 20MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
25000846
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 20MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
25000846
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 40MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
25000847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 40MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030430
|
| Hospital Charge Code |
25000847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 60 MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030630
|
| Hospital Charge Code |
25004055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 60 MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030630
|
| Hospital Charge Code |
25004055
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
|
LATUDA 80MG TABLET
|
Facility
|
OP
|
$85.29
|
|
|
Service Code
|
NDC 63402030830
|
| Hospital Charge Code |
25000848
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.59 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem Medicaid |
$29.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Humana KY Medicaid |
$29.33
|
| Rate for Payer: Kentucky WC Medicaid |
$29.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$29.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.85
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
