|
LEVOTHYROXINE 25mcg CAPSULE
|
Facility
|
IP
|
$12.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.54
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna Commercial |
$10.15
|
| Rate for Payer: First Health Commercial |
$11.62
|
| Rate for Payer: Humana Commercial |
$10.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.76
|
| Rate for Payer: Ohio Health Group HMO |
$9.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.79
|
| Rate for Payer: PHCS Commercial |
$11.74
|
| Rate for Payer: United Healthcare All Payer |
$10.76
|
|
|
LEVOTHYROXINE 25mcg CAPSULE
|
Facility
|
OP
|
$12.23
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: Anthem Medicaid |
$4.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.54
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna Commercial |
$10.15
|
| Rate for Payer: First Health Commercial |
$11.62
|
| Rate for Payer: Humana Commercial |
$10.40
|
| Rate for Payer: Humana KY Medicaid |
$4.21
|
| Rate for Payer: Kentucky WC Medicaid |
$4.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.76
|
| Rate for Payer: Ohio Health Group HMO |
$9.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.79
|
| Rate for Payer: PHCS Commercial |
$11.74
|
| Rate for Payer: United Healthcare All Payer |
$10.76
|
|
|
LEVSIN (HYOSCYAMINE 0.125MG/1T
|
Facility
|
OP
|
$4.88
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
25000863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
LEVSIN (HYOSCYAMINE 0.125MG/1T
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
NDC 47781001101
|
| Hospital Charge Code |
25000863
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
LEXAPRO (ESCITA OXALA) 10 MG T
|
Facility
|
OP
|
$4.35
|
|
|
Service Code
|
NDC 904642661
|
| Hospital Charge Code |
25000865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Humana KY Medicaid |
$1.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem Medicaid |
$1.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
|
|
LEXAPRO (ESCITA OXALA) 10 MG T
|
Facility
|
IP
|
$4.35
|
|
|
Service Code
|
NDC 904642661
|
| Hospital Charge Code |
25000865
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.18 |
| Rate for Payer: Aetna Commercial |
$3.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.61
|
| Rate for Payer: First Health Commercial |
$4.13
|
| Rate for Payer: Humana Commercial |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.83
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.18
|
| Rate for Payer: United Healthcare All Payer |
$3.83
|
|
|
LEXISCAN 0.1MG(0.4MG/5ML SYR
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
25002340
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$121.92 |
| Rate for Payer: Aetna Commercial |
$97.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.06
|
| Rate for Payer: Cash Price |
$63.50
|
| Rate for Payer: Cigna Commercial |
$105.41
|
| Rate for Payer: First Health Commercial |
$120.65
|
| Rate for Payer: Humana Commercial |
$107.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.76
|
| Rate for Payer: Ohio Health Group HMO |
$95.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.37
|
| Rate for Payer: PHCS Commercial |
$121.92
|
| Rate for Payer: United Healthcare All Payer |
$111.76
|
|
|
LEXISCAN 0.1MG(0.4MG/5ML SYR
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
HCPCS J2785
|
| Hospital Charge Code |
25002340
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.51 |
| Max. Negotiated Rate |
$121.92 |
| Rate for Payer: Aetna Commercial |
$97.79
|
| Rate for Payer: Anthem Medicaid |
$43.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$99.06
|
| Rate for Payer: Cash Price |
$63.50
|
| Rate for Payer: Cigna Commercial |
$105.41
|
| Rate for Payer: First Health Commercial |
$120.65
|
| Rate for Payer: Humana Commercial |
$107.95
|
| Rate for Payer: Humana KY Medicaid |
$43.68
|
| Rate for Payer: Kentucky WC Medicaid |
$44.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.76
|
| Rate for Payer: Ohio Health Group HMO |
$95.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.37
|
| Rate for Payer: PHCS Commercial |
$121.92
|
| Rate for Payer: United Healthcare All Payer |
$111.76
|
|
|
LFIT ANATOMIC X3 LINER 36D
|
Facility
|
IP
|
$7,733.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,005.30 |
| Max. Negotiated Rate |
$7,423.73 |
| Rate for Payer: Aetna Commercial |
$5,954.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,031.78
|
| Rate for Payer: Cash Price |
$3,866.52
|
| Rate for Payer: Cigna Commercial |
$6,418.43
|
| Rate for Payer: First Health Commercial |
$7,346.40
|
| Rate for Payer: Humana Commercial |
$6,573.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,341.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,706.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,319.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,805.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,799.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,546.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,005.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,397.25
|
| Rate for Payer: PHCS Commercial |
$7,423.73
|
| Rate for Payer: United Healthcare All Payer |
$6,805.08
|
|
|
LFIT ANATOMIC X3 LINER 36D
|
Facility
|
OP
|
$7,733.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,005.30 |
| Max. Negotiated Rate |
$7,423.73 |
| Rate for Payer: Aetna Commercial |
$5,954.45
|
| Rate for Payer: Anthem Medicaid |
$2,659.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,031.78
|
| Rate for Payer: Cash Price |
$3,866.52
|
| Rate for Payer: Cigna Commercial |
$6,418.43
|
| Rate for Payer: First Health Commercial |
$7,346.40
|
| Rate for Payer: Humana Commercial |
$6,573.09
|
| Rate for Payer: Humana KY Medicaid |
$2,659.40
|
| Rate for Payer: Kentucky WC Medicaid |
$2,686.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,341.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,706.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,319.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,712.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,805.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,799.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,546.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,005.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,397.25
|
| Rate for Payer: PHCS Commercial |
$7,423.73
|
| Rate for Payer: United Healthcare All Payer |
$6,805.08
|
|
|
LFIT ANATOMIC X3 LINER 40E
|
Facility
|
OP
|
$9,115.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,185.07 |
| Max. Negotiated Rate |
$8,751.32 |
| Rate for Payer: Aetna Commercial |
$7,019.29
|
| Rate for Payer: Anthem Medicaid |
$3,134.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,110.45
|
| Rate for Payer: Cash Price |
$4,557.98
|
| Rate for Payer: Cigna Commercial |
$7,566.25
|
| Rate for Payer: First Health Commercial |
$8,660.16
|
| Rate for Payer: Humana Commercial |
$7,748.57
|
| Rate for Payer: Humana KY Medicaid |
$3,134.98
|
| Rate for Payer: Kentucky WC Medicaid |
$3,166.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,475.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,727.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,734.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,197.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,022.04
|
| Rate for Payer: Ohio Health Group HMO |
$6,836.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,823.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,185.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,825.95
|
| Rate for Payer: PHCS Commercial |
$8,751.32
|
| Rate for Payer: United Healthcare All Payer |
$8,022.04
|
|
|
LFIT ANATOMIC X3 LINER 40E
|
Facility
|
IP
|
$9,115.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,185.07 |
| Max. Negotiated Rate |
$8,751.32 |
| Rate for Payer: Aetna Commercial |
$7,019.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,110.45
|
| Rate for Payer: Cash Price |
$4,557.98
|
| Rate for Payer: Cigna Commercial |
$7,566.25
|
| Rate for Payer: First Health Commercial |
$8,660.16
|
| Rate for Payer: Humana Commercial |
$7,748.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,475.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,727.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,734.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,022.04
|
| Rate for Payer: Ohio Health Group HMO |
$6,836.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,823.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,185.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,825.95
|
| Rate for Payer: PHCS Commercial |
$8,751.32
|
| Rate for Payer: United Healthcare All Payer |
$8,022.04
|
|
|
LFIT ANATOMIC X3 LINER 44F
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
LFIT ANATOMIC X3 LINER 44F
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
LFIT ANATOMIC X3 LINER 44G
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
LFIT ANATOMIC X3 LINER 44G
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
LFIT ANTOMC X3 LINR 44I 8.6MM
|
Facility
|
IP
|
$10,965.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
LFIT ANTOMC X3 LINR 44I 8.6MM
|
Facility
|
OP
|
$10,965.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem Medicaid |
$3,770.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Humana KY Medicaid |
$3,770.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,809.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,846.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
LFIT ANTOMC X3 LINR 44J 10.6M
|
Facility
|
OP
|
$10,965.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem Medicaid |
$3,770.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Humana KY Medicaid |
$3,770.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,809.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,846.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
LFIT ANTOMC X3 LINR 44J 10.6M
|
Facility
|
IP
|
$10,965.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
LGCY-LPS-MBLE ART SURF SZGX10M
|
Facility
|
OP
|
$7,543.54
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.66 |
| Max. Negotiated Rate |
$7,241.80 |
| Rate for Payer: Aetna Commercial |
$5,808.53
|
| Rate for Payer: Anthem Medicaid |
$2,594.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,883.96
|
| Rate for Payer: Cash Price |
$3,771.77
|
| Rate for Payer: Cigna Commercial |
$6,261.14
|
| Rate for Payer: First Health Commercial |
$7,166.36
|
| Rate for Payer: Humana Commercial |
$6,412.01
|
| Rate for Payer: Humana KY Medicaid |
$2,594.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,620.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,185.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,567.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,646.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,638.32
|
| Rate for Payer: Ohio Health Group HMO |
$5,657.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.50
|
| Rate for Payer: PHCS Commercial |
$7,241.80
|
| Rate for Payer: United Healthcare All Payer |
$6,638.32
|
|
|
LGCY-LPS-MBLE ART SURF SZGX10M
|
Facility
|
IP
|
$7,543.54
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.66 |
| Max. Negotiated Rate |
$7,241.80 |
| Rate for Payer: Aetna Commercial |
$5,808.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,883.96
|
| Rate for Payer: Cash Price |
$3,771.77
|
| Rate for Payer: Cigna Commercial |
$6,261.14
|
| Rate for Payer: First Health Commercial |
$7,166.36
|
| Rate for Payer: Humana Commercial |
$6,412.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,185.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,567.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,638.32
|
| Rate for Payer: Ohio Health Group HMO |
$5,657.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.50
|
| Rate for Payer: PHCS Commercial |
$7,241.80
|
| Rate for Payer: United Healthcare All Payer |
$6,638.32
|
|
|
LGCY PSTSTB LPS-FLX FM CMSZGRT
|
Facility
|
IP
|
$17,291.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.93 |
| Max. Negotiated Rate |
$16,600.09 |
| Rate for Payer: Aetna Commercial |
$13,314.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,487.57
|
| Rate for Payer: Cash Price |
$8,645.88
|
| Rate for Payer: Cigna Commercial |
$14,352.16
|
| Rate for Payer: First Health Commercial |
$16,427.17
|
| Rate for Payer: Humana Commercial |
$14,698.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,179.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,761.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,187.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,216.75
|
| Rate for Payer: Ohio Health Group HMO |
$12,968.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,458.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,247.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,360.45
|
| Rate for Payer: PHCS Commercial |
$16,600.09
|
| Rate for Payer: United Healthcare All Payer |
$15,216.75
|
|
|
LGCY PSTSTB LPS-FLX FM CMSZGRT
|
Facility
|
OP
|
$17,291.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,247.93 |
| Max. Negotiated Rate |
$16,600.09 |
| Rate for Payer: Aetna Commercial |
$13,314.66
|
| Rate for Payer: Anthem Medicaid |
$5,946.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,487.57
|
| Rate for Payer: Cash Price |
$8,645.88
|
| Rate for Payer: Cigna Commercial |
$14,352.16
|
| Rate for Payer: First Health Commercial |
$16,427.17
|
| Rate for Payer: Humana Commercial |
$14,698.00
|
| Rate for Payer: Humana KY Medicaid |
$5,946.64
|
| Rate for Payer: Kentucky WC Medicaid |
$6,007.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,179.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,761.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,187.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,065.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,216.75
|
| Rate for Payer: Ohio Health Group HMO |
$12,968.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,458.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,247.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,360.45
|
| Rate for Payer: PHCS Commercial |
$16,600.09
|
| Rate for Payer: United Healthcare All Payer |
$15,216.75
|
|
|
LG DRES/OR DETRI BURN W/O ANES
|
Facility
|
IP
|
$179.00
|
|
| Hospital Charge Code |
45000332
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$23.27 |
| Max. Negotiated Rate |
$171.84 |
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$139.62
|
| Rate for Payer: Cash Price |
$89.50
|
| Rate for Payer: Cigna Commercial |
$148.57
|
| Rate for Payer: First Health Commercial |
$170.05
|
| Rate for Payer: Humana Commercial |
$152.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$146.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$132.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$53.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$157.52
|
| Rate for Payer: Ohio Health Group HMO |
$134.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$35.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.49
|
| Rate for Payer: PHCS Commercial |
$171.84
|
| Rate for Payer: United Healthcare All Payer |
$157.52
|
|
