|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
IP
|
$531.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
761T0134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.30 |
| Max. Negotiated Rate |
$509.76 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$159.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
761T0134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
OP
|
$835.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
76100134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$287.16 |
| Max. Negotiated Rate |
$801.60 |
| Rate for Payer: Aetna Commercial |
$642.95
|
| Rate for Payer: Anthem Medicaid |
$287.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$651.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cigna Commercial |
$693.05
|
| Rate for Payer: First Health Commercial |
$793.25
|
| Rate for Payer: Humana Commercial |
$709.75
|
| Rate for Payer: Humana KY Medicaid |
$287.16
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$290.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$684.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$292.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$734.80
|
| Rate for Payer: Ohio Health Group HMO |
$626.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.15
|
| Rate for Payer: PHCS Commercial |
$801.60
|
| Rate for Payer: United Healthcare All Payer |
$734.80
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
OP
|
$531.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
45000055
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$182.61 |
| Max. Negotiated Rate |
$516.82 |
| Rate for Payer: Aetna Commercial |
$408.87
|
| Rate for Payer: Anthem Medicaid |
$182.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$414.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cash Price |
$265.50
|
| Rate for Payer: Cigna Commercial |
$440.73
|
| Rate for Payer: First Health Commercial |
$504.45
|
| Rate for Payer: Humana Commercial |
$451.35
|
| Rate for Payer: Humana KY Medicaid |
$182.61
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$184.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$435.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$391.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$186.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$467.28
|
| Rate for Payer: Ohio Health Group HMO |
$398.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$424.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$461.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$366.39
|
| Rate for Payer: PHCS Commercial |
$509.76
|
| Rate for Payer: United Healthcare All Payer |
$467.28
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Professional
|
Both
|
$835.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
76100134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.63 |
| Max. Negotiated Rate |
$501.00 |
| Rate for Payer: Aetna Commercial |
$223.55
|
| Rate for Payer: Ambetter Exchange |
$141.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$89.86
|
| Rate for Payer: Anthem Medicaid |
$82.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$141.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$141.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$169.64
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cigna Commercial |
$302.40
|
| Rate for Payer: Healthspan PPO |
$259.20
|
| Rate for Payer: Humana Medicaid |
$82.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$141.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.28
|
| Rate for Payer: Molina Healthcare Passport |
$82.63
|
| Rate for Payer: Multiplan PHCS |
$501.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$183.78
|
| Rate for Payer: UHCCP Medicaid |
$94.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$83.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$141.37
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Professional
|
Both
|
$304.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
761P0134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.63 |
| Max. Negotiated Rate |
$302.40 |
| Rate for Payer: Aetna Commercial |
$223.55
|
| Rate for Payer: Ambetter Exchange |
$141.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$89.86
|
| Rate for Payer: Anthem Medicaid |
$82.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$141.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$141.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$169.64
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cash Price |
$152.00
|
| Rate for Payer: Cigna Commercial |
$302.40
|
| Rate for Payer: Healthspan PPO |
$259.20
|
| Rate for Payer: Humana Medicaid |
$82.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$200.76
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$141.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$141.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$84.28
|
| Rate for Payer: Molina Healthcare Passport |
$82.63
|
| Rate for Payer: Multiplan PHCS |
$182.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$183.78
|
| Rate for Payer: UHCCP Medicaid |
$94.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$83.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$141.37
|
|
|
LAYERED CLOSURE EXCPT HNDS/FET
|
Facility
|
IP
|
$835.00
|
|
|
Service Code
|
HCPCS 12031
|
| Hospital Charge Code |
76100134
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$250.50 |
| Max. Negotiated Rate |
$801.60 |
| Rate for Payer: Aetna Commercial |
$642.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$651.30
|
| Rate for Payer: Cash Price |
$417.50
|
| Rate for Payer: Cigna Commercial |
$693.05
|
| Rate for Payer: First Health Commercial |
$793.25
|
| Rate for Payer: Humana Commercial |
$709.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$684.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$616.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$250.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$734.80
|
| Rate for Payer: Ohio Health Group HMO |
$626.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$668.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$726.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$576.15
|
| Rate for Payer: PHCS Commercial |
$801.60
|
| Rate for Payer: United Healthcare All Payer |
$734.80
|
|
|
LAYRNGOSCOPY
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 31531
|
| Hospital Charge Code |
41000020
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$198.30 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$324.20
|
| Rate for Payer: Ambetter Exchange |
$198.30
|
| Rate for Payer: Anthem Medicaid |
$252.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$198.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$198.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$237.96
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$328.50
|
| Rate for Payer: Healthspan PPO |
$273.40
|
| Rate for Payer: Humana Medicaid |
$252.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$278.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$198.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.28
|
| Rate for Payer: Molina Healthcare Passport |
$252.24
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$257.79
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$254.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$198.30
|
|
|
LAYRNGOSCOPY
|
Facility
|
IP
|
$1,250.00
|
|
|
Service Code
|
HCPCS 31531
|
| Hospital Charge Code |
41000020
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$375.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$962.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$1,037.50
|
| Rate for Payer: First Health Commercial |
$1,187.50
|
| Rate for Payer: Humana Commercial |
$1,062.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$375.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.00
|
| Rate for Payer: Ohio Health Group HMO |
$937.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$862.50
|
| Rate for Payer: PHCS Commercial |
$1,200.00
|
| Rate for Payer: United Healthcare All Payer |
$1,100.00
|
|
|
LAYRNGOSCOPY
|
Facility
|
OP
|
$1,250.00
|
|
|
Service Code
|
HCPCS 31531
|
| Hospital Charge Code |
41000020
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$429.88 |
| Max. Negotiated Rate |
$4,769.34 |
| Rate for Payer: Aetna Commercial |
$962.50
|
| Rate for Payer: Anthem Medicaid |
$429.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,406.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$975.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,769.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,599.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$1,037.50
|
| Rate for Payer: First Health Commercial |
$1,187.50
|
| Rate for Payer: Humana Commercial |
$1,062.50
|
| Rate for Payer: Humana KY Medicaid |
$429.88
|
| Rate for Payer: Humana Medicare Advantage |
$3,406.67
|
| Rate for Payer: Kentucky WC Medicaid |
$434.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,025.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$922.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,088.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$438.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,100.00
|
| Rate for Payer: Ohio Health Group HMO |
$937.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$862.50
|
| Rate for Payer: PHCS Commercial |
$1,200.00
|
| Rate for Payer: United Healthcare All Payer |
$1,100.00
|
|
|
LAYRNGOSCOPY(P
|
Professional
|
Both
|
$1,250.00
|
|
|
Service Code
|
HCPCS 31531
|
| Hospital Charge Code |
410P0020
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$198.30 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$324.20
|
| Rate for Payer: Ambetter Exchange |
$198.30
|
| Rate for Payer: Anthem Medicaid |
$252.24
|
| Rate for Payer: Buckeye Individual/Medicaid |
$198.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$198.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$237.96
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cash Price |
$625.00
|
| Rate for Payer: Cigna Commercial |
$328.50
|
| Rate for Payer: Healthspan PPO |
$273.40
|
| Rate for Payer: Humana Medicaid |
$252.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$278.84
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$198.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$198.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$257.28
|
| Rate for Payer: Molina Healthcare Passport |
$252.24
|
| Rate for Payer: Multiplan PHCS |
$750.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$257.79
|
| Rate for Payer: UHCCP Medicaid |
$437.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$254.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$198.30
|
|
|
L-CARNITINE 500MG TABLET
|
Facility
|
OP
|
$4.45
|
|
|
Service Code
|
NDC 30768003741
|
| Hospital Charge Code |
25000849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
L-CARNITINE 500MG TABLET
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 30768003741
|
| Hospital Charge Code |
25000849
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.27 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.23
|
| Rate for Payer: Humana Commercial |
$3.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.07
|
| Rate for Payer: PHCS Commercial |
$4.27
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
LCB 6FR 90CM
|
Facility
|
IP
|
$1,104.60
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$331.38 |
| Max. Negotiated Rate |
$1,060.42 |
| Rate for Payer: Aetna Commercial |
$850.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.59
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: Cigna Commercial |
$916.82
|
| Rate for Payer: First Health Commercial |
$1,049.37
|
| Rate for Payer: Humana Commercial |
$938.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$815.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$972.05
|
| Rate for Payer: Ohio Health Group HMO |
$828.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$883.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$762.17
|
| Rate for Payer: PHCS Commercial |
$1,060.42
|
| Rate for Payer: United Healthcare All Payer |
$972.05
|
|
|
LCB 6FR 90CM
|
Facility
|
OP
|
$1,104.60
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$331.38 |
| Max. Negotiated Rate |
$1,060.42 |
| Rate for Payer: Aetna Commercial |
$850.54
|
| Rate for Payer: Anthem Medicaid |
$379.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.59
|
| Rate for Payer: Cash Price |
$552.30
|
| Rate for Payer: Cigna Commercial |
$916.82
|
| Rate for Payer: First Health Commercial |
$1,049.37
|
| Rate for Payer: Humana Commercial |
$938.91
|
| Rate for Payer: Humana KY Medicaid |
$379.87
|
| Rate for Payer: Kentucky WC Medicaid |
$383.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$815.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$387.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$972.05
|
| Rate for Payer: Ohio Health Group HMO |
$828.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$883.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$762.17
|
| Rate for Payer: PHCS Commercial |
$1,060.42
|
| Rate for Payer: United Healthcare All Payer |
$972.05
|
|
|
LCB CATH 5F DIAG.
|
Facility
|
IP
|
$166.46
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$159.80 |
| Rate for Payer: Aetna Commercial |
$128.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$129.84
|
| Rate for Payer: Cash Price |
$83.23
|
| Rate for Payer: Cigna Commercial |
$138.16
|
| Rate for Payer: First Health Commercial |
$158.14
|
| Rate for Payer: Humana Commercial |
$141.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.48
|
| Rate for Payer: Ohio Health Group HMO |
$124.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$133.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$144.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.86
|
| Rate for Payer: PHCS Commercial |
$159.80
|
| Rate for Payer: United Healthcare All Payer |
$146.48
|
|
|
LCB CATH 5F DIAG.
|
Facility
|
OP
|
$166.46
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.94 |
| Max. Negotiated Rate |
$159.80 |
| Rate for Payer: Aetna Commercial |
$128.17
|
| Rate for Payer: Anthem Medicaid |
$57.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$129.84
|
| Rate for Payer: Cash Price |
$83.23
|
| Rate for Payer: Cigna Commercial |
$138.16
|
| Rate for Payer: First Health Commercial |
$158.14
|
| Rate for Payer: Humana Commercial |
$141.49
|
| Rate for Payer: Humana KY Medicaid |
$57.25
|
| Rate for Payer: Kentucky WC Medicaid |
$57.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$136.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$122.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$146.48
|
| Rate for Payer: Ohio Health Group HMO |
$124.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$133.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$144.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$114.86
|
| Rate for Payer: PHCS Commercial |
$159.80
|
| Rate for Payer: United Healthcare All Payer |
$146.48
|
|
|
LCCK 0D SZ3 5MM 31*31 CPL
|
Facility
|
IP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ3 5MM 31*31 CPL
|
Facility
|
OP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem Medicaid |
$9,360.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Humana KY Medicaid |
$9,360.72
|
| Rate for Payer: Kentucky WC Medicaid |
$9,455.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,548.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ3 5MM 36*31 CPL
|
Facility
|
IP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ3 5MM 36*31 CPL
|
Facility
|
OP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem Medicaid |
$9,360.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Humana KY Medicaid |
$9,360.72
|
| Rate for Payer: Kentucky WC Medicaid |
$9,455.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,548.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ4 5MM 31*31 CPL
|
Facility
|
OP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem Medicaid |
$9,360.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Humana KY Medicaid |
$9,360.72
|
| Rate for Payer: Kentucky WC Medicaid |
$9,455.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,548.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ4 5MM 31*31 CPL
|
Facility
|
IP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ4 5MM 36*31 CPL
|
Facility
|
IP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
|
LCCK 0D SZ4 5MM 36*31 CPL
|
Facility
|
OP
|
$27,219.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,165.79 |
| Max. Negotiated Rate |
$26,130.54 |
| Rate for Payer: Aetna Commercial |
$20,958.87
|
| Rate for Payer: Anthem Medicaid |
$9,360.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,231.06
|
| Rate for Payer: Cash Price |
$13,609.66
|
| Rate for Payer: Cigna Commercial |
$22,592.03
|
| Rate for Payer: First Health Commercial |
$25,858.34
|
| Rate for Payer: Humana Commercial |
$23,136.41
|
| Rate for Payer: Humana KY Medicaid |
$9,360.72
|
| Rate for Payer: Kentucky WC Medicaid |
$9,455.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,319.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,087.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,165.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,548.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,952.99
|
| Rate for Payer: Ohio Health Group HMO |
$20,414.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,775.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,680.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,781.32
|
| Rate for Payer: PHCS Commercial |
$26,130.54
|
| Rate for Payer: United Healthcare All Payer |
$23,952.99
|
|
