|
PH MONITOR(P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 91035
|
| Hospital Charge Code |
750P0002
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$684.78 |
| Rate for Payer: Healthspan PPO |
$560.38
|
| Rate for Payer: Aetna Commercial |
$684.78
|
| Rate for Payer: Anthem Medicaid |
$325.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$300.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$602.95
|
| Rate for Payer: Humana Medicaid |
$325.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$108.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$332.38
|
| Rate for Payer: Molina Healthcare Passport |
$325.86
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$210.00
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$329.12
|
|
|
PH MONITOR(T
|
Facility
|
OP
|
$726.00
|
|
|
Service Code
|
HCPCS 91034
|
| Hospital Charge Code |
750T0002
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$94.38 |
| Max. Negotiated Rate |
$696.96 |
| Rate for Payer: Aetna Commercial |
$559.02
|
| Rate for Payer: Anthem Medicaid |
$249.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$566.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$363.00
|
| Rate for Payer: Cash Price |
$363.00
|
| Rate for Payer: Cigna Commercial |
$602.58
|
| Rate for Payer: First Health Commercial |
$689.70
|
| Rate for Payer: Humana Commercial |
$617.10
|
| Rate for Payer: Humana KY Medicaid |
$249.67
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$252.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$595.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$535.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$254.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$638.88
|
| Rate for Payer: Ohio Health Group HMO |
$544.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.06
|
| Rate for Payer: PHCS Commercial |
$696.96
|
| Rate for Payer: United Healthcare All Payer |
$638.88
|
|
|
PH MONITOR(T
|
Facility
|
IP
|
$726.00
|
|
|
Service Code
|
HCPCS 91034
|
| Hospital Charge Code |
750T0002
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$94.38 |
| Max. Negotiated Rate |
$696.96 |
| Rate for Payer: Aetna Commercial |
$559.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$566.28
|
| Rate for Payer: Cash Price |
$363.00
|
| Rate for Payer: Cigna Commercial |
$602.58
|
| Rate for Payer: First Health Commercial |
$689.70
|
| Rate for Payer: Humana Commercial |
$617.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$595.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$535.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$638.88
|
| Rate for Payer: Ohio Health Group HMO |
$544.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$145.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$94.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$225.06
|
| Rate for Payer: PHCS Commercial |
$696.96
|
| Rate for Payer: United Healthcare All Payer |
$638.88
|
|
|
PHOENIX 1.8 5F
|
Facility
|
IP
|
$14,067.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,828.78 |
| Max. Negotiated Rate |
$13,504.80 |
| Rate for Payer: Aetna Commercial |
$10,831.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,972.65
|
| Rate for Payer: Cash Price |
$7,033.75
|
| Rate for Payer: Cigna Commercial |
$11,676.02
|
| Rate for Payer: First Health Commercial |
$13,364.12
|
| Rate for Payer: Humana Commercial |
$11,957.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,535.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,381.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,220.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,379.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,550.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,828.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,360.92
|
| Rate for Payer: PHCS Commercial |
$13,504.80
|
| Rate for Payer: United Healthcare All Payer |
$12,379.40
|
|
|
PHOENIX 1.8 5F
|
Facility
|
OP
|
$14,067.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,828.78 |
| Max. Negotiated Rate |
$13,504.80 |
| Rate for Payer: Aetna Commercial |
$10,831.98
|
| Rate for Payer: Anthem Medicaid |
$4,837.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,972.65
|
| Rate for Payer: Cash Price |
$7,033.75
|
| Rate for Payer: Cigna Commercial |
$11,676.02
|
| Rate for Payer: First Health Commercial |
$13,364.12
|
| Rate for Payer: Humana Commercial |
$11,957.38
|
| Rate for Payer: Humana KY Medicaid |
$4,837.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,887.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,535.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,381.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,220.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,934.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,379.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,550.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,828.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,360.92
|
| Rate for Payer: PHCS Commercial |
$13,504.80
|
| Rate for Payer: United Healthcare All Payer |
$12,379.40
|
|
|
PHOENIX 2.2 149CM 6F
|
Facility
|
OP
|
$14,067.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,828.78 |
| Max. Negotiated Rate |
$13,504.80 |
| Rate for Payer: Aetna Commercial |
$10,831.98
|
| Rate for Payer: Anthem Medicaid |
$4,837.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,972.65
|
| Rate for Payer: Cash Price |
$7,033.75
|
| Rate for Payer: Cigna Commercial |
$11,676.02
|
| Rate for Payer: First Health Commercial |
$13,364.12
|
| Rate for Payer: Humana Commercial |
$11,957.38
|
| Rate for Payer: Humana KY Medicaid |
$4,837.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,887.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,535.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,381.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,220.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,934.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,379.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,550.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,828.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,360.92
|
| Rate for Payer: PHCS Commercial |
$13,504.80
|
| Rate for Payer: United Healthcare All Payer |
$12,379.40
|
|
|
PHOENIX 2.2 149CM 6F
|
Facility
|
IP
|
$14,067.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,828.78 |
| Max. Negotiated Rate |
$13,504.80 |
| Rate for Payer: Aetna Commercial |
$10,831.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,972.65
|
| Rate for Payer: Cash Price |
$7,033.75
|
| Rate for Payer: Cigna Commercial |
$11,676.02
|
| Rate for Payer: First Health Commercial |
$13,364.12
|
| Rate for Payer: Humana Commercial |
$11,957.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,535.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,381.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,220.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,379.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,550.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,828.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,360.92
|
| Rate for Payer: PHCS Commercial |
$13,504.80
|
| Rate for Payer: United Healthcare All Payer |
$12,379.40
|
|
|
PHOENIX 2.4MM 127CM 7F
|
Facility
|
OP
|
$14,067.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,828.78 |
| Max. Negotiated Rate |
$13,504.80 |
| Rate for Payer: Aetna Commercial |
$10,831.98
|
| Rate for Payer: Anthem Medicaid |
$4,837.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,972.65
|
| Rate for Payer: Cash Price |
$7,033.75
|
| Rate for Payer: Cigna Commercial |
$11,676.02
|
| Rate for Payer: First Health Commercial |
$13,364.12
|
| Rate for Payer: Humana Commercial |
$11,957.38
|
| Rate for Payer: Humana KY Medicaid |
$4,837.81
|
| Rate for Payer: Kentucky WC Medicaid |
$4,887.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,535.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,381.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,220.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,934.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,379.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,550.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,828.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,360.92
|
| Rate for Payer: PHCS Commercial |
$13,504.80
|
| Rate for Payer: United Healthcare All Payer |
$12,379.40
|
|
|
PHOENIX 2.4MM 127CM 7F
|
Facility
|
IP
|
$14,067.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,828.78 |
| Max. Negotiated Rate |
$13,504.80 |
| Rate for Payer: Aetna Commercial |
$10,831.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,972.65
|
| Rate for Payer: Cash Price |
$7,033.75
|
| Rate for Payer: Cigna Commercial |
$11,676.02
|
| Rate for Payer: First Health Commercial |
$13,364.12
|
| Rate for Payer: Humana Commercial |
$11,957.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,535.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,381.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,220.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,379.40
|
| Rate for Payer: Ohio Health Group HMO |
$10,550.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,813.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,828.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,360.92
|
| Rate for Payer: PHCS Commercial |
$13,504.80
|
| Rate for Payer: United Healthcare All Payer |
$12,379.40
|
|
|
PHOENIX LIGHT SUPPORT GUIDWIRE
|
Facility
|
IP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$1,833.60 |
| Rate for Payer: Aetna Commercial |
$1,470.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.80
|
| Rate for Payer: Cash Price |
$955.00
|
| Rate for Payer: Cigna Commercial |
$1,585.30
|
| Rate for Payer: First Health Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial |
$1,623.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,566.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.10
|
| Rate for Payer: PHCS Commercial |
$1,833.60
|
| Rate for Payer: United Healthcare All Payer |
$1,680.80
|
|
|
PHOENIX LIGHT SUPPORT GUIDWIRE
|
Facility
|
OP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$1,833.60 |
| Rate for Payer: Aetna Commercial |
$1,470.70
|
| Rate for Payer: Anthem Medicaid |
$656.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.80
|
| Rate for Payer: Cash Price |
$955.00
|
| Rate for Payer: Cigna Commercial |
$1,585.30
|
| Rate for Payer: First Health Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial |
$1,623.50
|
| Rate for Payer: Humana KY Medicaid |
$656.85
|
| Rate for Payer: Kentucky WC Medicaid |
$663.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,566.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$670.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.10
|
| Rate for Payer: PHCS Commercial |
$1,833.60
|
| Rate for Payer: United Healthcare All Payer |
$1,680.80
|
|
|
PHOSLO(CALCIUM ACET 667MG/1TAB
|
Facility
|
OP
|
$9.40
|
|
|
Service Code
|
NDC 68084047901
|
| Hospital Charge Code |
25001185
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.02 |
| Rate for Payer: Aetna Commercial |
$7.24
|
| Rate for Payer: Anthem Medicaid |
$3.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.33
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna Commercial |
$7.80
|
| Rate for Payer: First Health Commercial |
$8.93
|
| Rate for Payer: Humana Commercial |
$7.99
|
| Rate for Payer: Humana KY Medicaid |
$3.23
|
| Rate for Payer: Kentucky WC Medicaid |
$3.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.27
|
| Rate for Payer: Ohio Health Group HMO |
$7.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$9.02
|
| Rate for Payer: United Healthcare All Payer |
$8.27
|
|
|
PHOSLO(CALCIUM ACET 667MG/1TAB
|
Facility
|
IP
|
$9.40
|
|
|
Service Code
|
NDC 68084047901
|
| Hospital Charge Code |
25001185
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$9.02 |
| Rate for Payer: Aetna Commercial |
$7.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.33
|
| Rate for Payer: Cash Price |
$4.70
|
| Rate for Payer: Cigna Commercial |
$7.80
|
| Rate for Payer: First Health Commercial |
$8.93
|
| Rate for Payer: Humana Commercial |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.27
|
| Rate for Payer: Ohio Health Group HMO |
$7.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$9.02
|
| Rate for Payer: United Healthcare All Payer |
$8.27
|
|
|
PHOSPHATIDYL GLYCEROL
|
Facility
|
OP
|
$154.00
|
|
|
Service Code
|
HCPCS 84081
|
| Hospital Charge Code |
30000473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.52 |
| Max. Negotiated Rate |
$147.84 |
| Rate for Payer: Aetna Commercial |
$118.58
|
| Rate for Payer: Anthem Medicaid |
$16.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.52
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna Commercial |
$127.82
|
| Rate for Payer: First Health Commercial |
$146.30
|
| Rate for Payer: Humana Commercial |
$130.90
|
| Rate for Payer: Humana KY Medicaid |
$16.52
|
| Rate for Payer: Humana Medicare Advantage |
$16.52
|
| Rate for Payer: Kentucky WC Medicaid |
$16.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$126.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$113.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$16.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$135.52
|
| Rate for Payer: Ohio Health Group HMO |
$115.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.74
|
| Rate for Payer: PHCS Commercial |
$147.84
|
| Rate for Payer: United Healthcare All Payer |
$135.52
|
|
|
PHOSPHATIDYL GLYCEROL
|
Facility
|
IP
|
$154.00
|
|
|
Service Code
|
HCPCS 84081
|
| Hospital Charge Code |
30000473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.02 |
| Max. Negotiated Rate |
$147.84 |
| Rate for Payer: Aetna Commercial |
$118.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.66
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: Cigna Commercial |
$127.82
|
| Rate for Payer: First Health Commercial |
$146.30
|
| Rate for Payer: Humana Commercial |
$130.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$126.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$113.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$135.52
|
| Rate for Payer: Ohio Health Group HMO |
$115.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$30.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.74
|
| Rate for Payer: PHCS Commercial |
$147.84
|
| Rate for Payer: United Healthcare All Payer |
$135.52
|
|
|
PHOSPHORUS
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
30000475
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem Medicaid |
$4.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.74
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Humana KY Medicaid |
$4.74
|
| Rate for Payer: Humana Medicare Advantage |
$4.74
|
| Rate for Payer: Kentucky WC Medicaid |
$4.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.05
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
PHOSPHORUS
|
Professional
|
Both
|
$55.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
30000475
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.84 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna Commercial |
$9.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$55.00
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: Healthspan PPO |
$4.97
|
| Rate for Payer: Multiplan PHCS |
$33.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$38.50
|
| Rate for Payer: UHCCP Medicaid |
$19.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2.84
|
|
|
PHOSPHORUS
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 84100
|
| Hospital Charge Code |
30000475
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$52.80 |
| Rate for Payer: Aetna Commercial |
$42.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44.16
|
| Rate for Payer: Cash Price |
$27.50
|
| Rate for Payer: Cigna Commercial |
$45.65
|
| Rate for Payer: First Health Commercial |
$52.25
|
| Rate for Payer: Humana Commercial |
$46.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$48.40
|
| Rate for Payer: Ohio Health Group HMO |
$41.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.05
|
| Rate for Payer: PHCS Commercial |
$52.80
|
| Rate for Payer: United Healthcare All Payer |
$48.40
|
|
|
PHOTOCHEMOTHERAPY WITH UV-B
|
Professional
|
Both
|
$197.00
|
|
|
Service Code
|
HCPCS 96910
|
| Hospital Charge Code |
76102704
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$15.72 |
| Max. Negotiated Rate |
$197.00 |
| Rate for Payer: Aetna Commercial |
$93.82
|
| Rate for Payer: Anthem Medicaid |
$15.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$197.00
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Cash Price |
$98.50
|
| Rate for Payer: Cigna Commercial |
$85.25
|
| Rate for Payer: Humana Medicaid |
$15.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$80.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$16.03
|
| Rate for Payer: Molina Healthcare Passport |
$15.72
|
| Rate for Payer: Multiplan PHCS |
$118.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$137.90
|
| Rate for Payer: UHCCP Medicaid |
$68.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.88
|
|
|
PHOTOFIX BOVNE PERCRDM 0.8*8CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PHOTOFIX BOVNE PERCRDM 0.8*8CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PHOXILLUM B22K4/0 SOLUTION
|
Facility
|
IP
|
$106.90
|
|
|
Service Code
|
NDC 24571011705
|
| Hospital Charge Code |
25003734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Aetna Commercial |
$82.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.38
|
| Rate for Payer: Cash Price |
$53.45
|
| Rate for Payer: Cigna Commercial |
$88.73
|
| Rate for Payer: First Health Commercial |
$101.56
|
| Rate for Payer: Humana Commercial |
$90.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.07
|
| Rate for Payer: Ohio Health Group HMO |
$80.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.14
|
| Rate for Payer: PHCS Commercial |
$102.62
|
| Rate for Payer: United Healthcare All Payer |
$94.07
|
|
|
PHOXILLUM B22K4/0 SOLUTION
|
Facility
|
OP
|
$106.90
|
|
|
Service Code
|
NDC 24571011705
|
| Hospital Charge Code |
25003734
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Aetna Commercial |
$82.31
|
| Rate for Payer: Anthem Medicaid |
$36.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.38
|
| Rate for Payer: Cash Price |
$53.45
|
| Rate for Payer: Cigna Commercial |
$88.73
|
| Rate for Payer: First Health Commercial |
$101.56
|
| Rate for Payer: Humana Commercial |
$90.86
|
| Rate for Payer: Humana KY Medicaid |
$36.76
|
| Rate for Payer: Kentucky WC Medicaid |
$37.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.07
|
| Rate for Payer: Ohio Health Group HMO |
$80.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.14
|
| Rate for Payer: PHCS Commercial |
$102.62
|
| Rate for Payer: United Healthcare All Payer |
$94.07
|
|
|
PHOXILLUM BK 4/2.5 SOLUTION
|
Facility
|
OP
|
$106.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Aetna Commercial |
$82.31
|
| Rate for Payer: Anthem Medicaid |
$36.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.38
|
| Rate for Payer: Cash Price |
$53.45
|
| Rate for Payer: Cigna Commercial |
$88.73
|
| Rate for Payer: First Health Commercial |
$101.56
|
| Rate for Payer: Humana Commercial |
$90.86
|
| Rate for Payer: Humana KY Medicaid |
$36.76
|
| Rate for Payer: Kentucky WC Medicaid |
$37.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$37.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.07
|
| Rate for Payer: Ohio Health Group HMO |
$80.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.14
|
| Rate for Payer: PHCS Commercial |
$102.62
|
| Rate for Payer: United Healthcare All Payer |
$94.07
|
|
|
PHOXILLUM BK 4/2.5 SOLUTION
|
Facility
|
IP
|
$106.90
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$102.62 |
| Rate for Payer: Aetna Commercial |
$82.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.38
|
| Rate for Payer: Cash Price |
$53.45
|
| Rate for Payer: Cigna Commercial |
$88.73
|
| Rate for Payer: First Health Commercial |
$101.56
|
| Rate for Payer: Humana Commercial |
$90.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.07
|
| Rate for Payer: Ohio Health Group HMO |
$80.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$33.14
|
| Rate for Payer: PHCS Commercial |
$102.62
|
| Rate for Payer: United Healthcare All Payer |
$94.07
|
|
