|
PAIN EASE 116mL
|
Facility
|
IP
|
$1.82
|
|
|
Service Code
|
NDC 386000803
|
| Hospital Charge Code |
25003336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.42
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna Commercial |
$1.51
|
| Rate for Payer: First Health Commercial |
$1.73
|
| Rate for Payer: Humana Commercial |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.60
|
| Rate for Payer: Ohio Health Group HMO |
$1.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.26
|
| Rate for Payer: PHCS Commercial |
$1.75
|
| Rate for Payer: United Healthcare All Payer |
$1.60
|
|
|
PAIN EASE 116mL
|
Facility
|
OP
|
$1.82
|
|
|
Service Code
|
NDC 386000803
|
| Hospital Charge Code |
25003336
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: Anthem Medicaid |
$0.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1.42
|
| Rate for Payer: Cash Price |
$0.91
|
| Rate for Payer: Cigna Commercial |
$1.51
|
| Rate for Payer: First Health Commercial |
$1.73
|
| Rate for Payer: Humana Commercial |
$1.55
|
| Rate for Payer: Humana KY Medicaid |
$0.63
|
| Rate for Payer: Kentucky WC Medicaid |
$0.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1.60
|
| Rate for Payer: Ohio Health Group HMO |
$1.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.26
|
| Rate for Payer: PHCS Commercial |
$1.75
|
| Rate for Payer: United Healthcare All Payer |
$1.60
|
|
|
PAIN EASE 30mL
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 386000804
|
| Hospital Charge Code |
25004386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Anthem Medicaid |
$1.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.73
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna Commercial |
$2.90
|
| Rate for Payer: First Health Commercial |
$3.33
|
| Rate for Payer: Humana Commercial |
$2.98
|
| Rate for Payer: Humana KY Medicaid |
$1.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.08
|
| Rate for Payer: Ohio Health Group HMO |
$2.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.42
|
| Rate for Payer: PHCS Commercial |
$3.36
|
| Rate for Payer: United Healthcare All Payer |
$3.08
|
|
|
PAIN EASE 30mL
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 386000804
|
| Hospital Charge Code |
25004386
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$3.36 |
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.73
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cigna Commercial |
$2.90
|
| Rate for Payer: First Health Commercial |
$3.33
|
| Rate for Payer: Humana Commercial |
$2.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.08
|
| Rate for Payer: Ohio Health Group HMO |
$2.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.42
|
| Rate for Payer: PHCS Commercial |
$3.36
|
| Rate for Payer: United Healthcare All Payer |
$3.08
|
|
|
PAIR/CUT BEN HYPERKER LES 4+
|
Professional
|
Both
|
$402.26
|
|
|
Service Code
|
HCPCS 11057
|
| Hospital Charge Code |
76100033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$241.36 |
| Rate for Payer: Aetna Commercial |
$65.04
|
| Rate for Payer: Ambetter Exchange |
$26.78
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.43
|
| Rate for Payer: Anthem Medicaid |
$22.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.14
|
| Rate for Payer: Cash Price |
$201.13
|
| Rate for Payer: Cash Price |
$201.13
|
| Rate for Payer: Cigna Commercial |
$92.25
|
| Rate for Payer: Healthspan PPO |
$80.68
|
| Rate for Payer: Humana Medicaid |
$22.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.56
|
| Rate for Payer: Molina Healthcare Passport |
$22.12
|
| Rate for Payer: Multiplan PHCS |
$241.36
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.81
|
| Rate for Payer: UHCCP Medicaid |
$22.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.78
|
|
|
PAIR/CUT BEN HYPERKER LES 4+
|
Facility
|
OP
|
$402.26
|
|
|
Service Code
|
HCPCS 11057
|
| Hospital Charge Code |
76100033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$138.34 |
| Max. Negotiated Rate |
$386.17 |
| Rate for Payer: Aetna Commercial |
$309.74
|
| Rate for Payer: Anthem Medicaid |
$138.34
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$313.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$201.13
|
| Rate for Payer: Cash Price |
$201.13
|
| Rate for Payer: Cigna Commercial |
$333.88
|
| Rate for Payer: First Health Commercial |
$382.15
|
| Rate for Payer: Humana Commercial |
$341.92
|
| Rate for Payer: Humana KY Medicaid |
$138.34
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$139.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$329.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$296.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$141.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$353.99
|
| Rate for Payer: Ohio Health Group HMO |
$301.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$321.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$349.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$277.56
|
| Rate for Payer: PHCS Commercial |
$386.17
|
| Rate for Payer: United Healthcare All Payer |
$353.99
|
|
|
PAIR/CUT BEN HYPERKER LES 4+
|
Facility
|
IP
|
$402.26
|
|
|
Service Code
|
HCPCS 11057
|
| Hospital Charge Code |
76100033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$120.68 |
| Max. Negotiated Rate |
$386.17 |
| Rate for Payer: Aetna Commercial |
$309.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$313.76
|
| Rate for Payer: Cash Price |
$201.13
|
| Rate for Payer: Cigna Commercial |
$333.88
|
| Rate for Payer: First Health Commercial |
$382.15
|
| Rate for Payer: Humana Commercial |
$341.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$329.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$296.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$120.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$353.99
|
| Rate for Payer: Ohio Health Group HMO |
$301.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$321.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$349.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$277.56
|
| Rate for Payer: PHCS Commercial |
$386.17
|
| Rate for Payer: United Healthcare All Payer |
$353.99
|
|
|
PAIR/CUT BEN HYPERKER LES 4+(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 11057
|
| Hospital Charge Code |
761P0033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$21.43 |
| Max. Negotiated Rate |
$92.25 |
| Rate for Payer: Aetna Commercial |
$65.04
|
| Rate for Payer: Ambetter Exchange |
$26.78
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.43
|
| Rate for Payer: Anthem Medicaid |
$22.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$26.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$26.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$32.14
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$92.25
|
| Rate for Payer: Healthspan PPO |
$80.68
|
| Rate for Payer: Humana Medicaid |
$22.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$46.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$26.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$22.56
|
| Rate for Payer: Molina Healthcare Passport |
$22.12
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$34.81
|
| Rate for Payer: UHCCP Medicaid |
$22.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$22.34
|
| Rate for Payer: Wellcare Medicare Advantage |
$26.78
|
|
|
PAIR/CUT BEN HYPERKER LES 4+(T
|
Facility
|
IP
|
$252.26
|
|
|
Service Code
|
HCPCS 11057
|
| Hospital Charge Code |
761T0033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.68 |
| Max. Negotiated Rate |
$242.17 |
| Rate for Payer: Aetna Commercial |
$194.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.76
|
| Rate for Payer: Cash Price |
$126.13
|
| Rate for Payer: Cigna Commercial |
$209.38
|
| Rate for Payer: First Health Commercial |
$239.65
|
| Rate for Payer: Humana Commercial |
$214.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.99
|
| Rate for Payer: Ohio Health Group HMO |
$189.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.06
|
| Rate for Payer: PHCS Commercial |
$242.17
|
| Rate for Payer: United Healthcare All Payer |
$221.99
|
|
|
PAIR/CUT BEN HYPERKER LES 4+(T
|
Facility
|
OP
|
$252.26
|
|
|
Service Code
|
HCPCS 11057
|
| Hospital Charge Code |
761T0033
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$86.75 |
| Max. Negotiated Rate |
$257.03 |
| Rate for Payer: Aetna Commercial |
$194.24
|
| Rate for Payer: Anthem Medicaid |
$86.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$183.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$196.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$257.03
|
| Rate for Payer: CareSource Just4Me Medicare |
$247.85
|
| Rate for Payer: Cash Price |
$126.13
|
| Rate for Payer: Cash Price |
$126.13
|
| Rate for Payer: Cigna Commercial |
$209.38
|
| Rate for Payer: First Health Commercial |
$239.65
|
| Rate for Payer: Humana Commercial |
$214.42
|
| Rate for Payer: Humana KY Medicaid |
$86.75
|
| Rate for Payer: Humana Medicare Advantage |
$183.59
|
| Rate for Payer: Kentucky WC Medicaid |
$87.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$206.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$186.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$88.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$221.99
|
| Rate for Payer: Ohio Health Group HMO |
$189.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$201.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$219.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$174.06
|
| Rate for Payer: PHCS Commercial |
$242.17
|
| Rate for Payer: United Healthcare All Payer |
$221.99
|
|
|
PALACOS LV 1*40 SINGLE
|
Facility
|
IP
|
$1,811.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$543.33 |
| Max. Negotiated Rate |
$1,738.66 |
| Rate for Payer: Aetna Commercial |
$1,394.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,412.66
|
| Rate for Payer: Cash Price |
$905.55
|
| Rate for Payer: Cigna Commercial |
$1,503.21
|
| Rate for Payer: First Health Commercial |
$1,720.55
|
| Rate for Payer: Humana Commercial |
$1,539.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,336.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,593.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,358.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,448.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,575.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,249.66
|
| Rate for Payer: PHCS Commercial |
$1,738.66
|
| Rate for Payer: United Healthcare All Payer |
$1,593.77
|
|
|
PALACOS LV 1*40 SINGLE
|
Facility
|
OP
|
$1,811.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$543.33 |
| Max. Negotiated Rate |
$1,738.66 |
| Rate for Payer: Aetna Commercial |
$1,394.55
|
| Rate for Payer: Anthem Medicaid |
$622.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,412.66
|
| Rate for Payer: Cash Price |
$905.55
|
| Rate for Payer: Cigna Commercial |
$1,503.21
|
| Rate for Payer: First Health Commercial |
$1,720.55
|
| Rate for Payer: Humana Commercial |
$1,539.43
|
| Rate for Payer: Humana KY Medicaid |
$622.84
|
| Rate for Payer: Kentucky WC Medicaid |
$629.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,336.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,593.77
|
| Rate for Payer: Ohio Health Group HMO |
$1,358.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,448.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,575.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,249.66
|
| Rate for Payer: PHCS Commercial |
$1,738.66
|
| Rate for Payer: United Healthcare All Payer |
$1,593.77
|
|
|
PALACOS LVG 1*40 SINGLE
|
Facility
|
OP
|
$3,666.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,099.86 |
| Max. Negotiated Rate |
$3,519.55 |
| Rate for Payer: Aetna Commercial |
$2,822.97
|
| Rate for Payer: Anthem Medicaid |
$1,260.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,859.64
|
| Rate for Payer: Cash Price |
$1,833.10
|
| Rate for Payer: Cigna Commercial |
$3,042.95
|
| Rate for Payer: First Health Commercial |
$3,482.89
|
| Rate for Payer: Humana Commercial |
$3,116.27
|
| Rate for Payer: Humana KY Medicaid |
$1,260.81
|
| Rate for Payer: Kentucky WC Medicaid |
$1,273.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,006.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,705.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,099.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,286.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,226.26
|
| Rate for Payer: Ohio Health Group HMO |
$2,749.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,932.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,189.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,529.68
|
| Rate for Payer: PHCS Commercial |
$3,519.55
|
| Rate for Payer: United Healthcare All Payer |
$3,226.26
|
|
|
PALACOS LVG 1*40 SINGLE
|
Facility
|
IP
|
$3,666.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,099.86 |
| Max. Negotiated Rate |
$3,519.55 |
| Rate for Payer: Aetna Commercial |
$2,822.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,859.64
|
| Rate for Payer: Cash Price |
$1,833.10
|
| Rate for Payer: Cigna Commercial |
$3,042.95
|
| Rate for Payer: First Health Commercial |
$3,482.89
|
| Rate for Payer: Humana Commercial |
$3,116.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,006.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,705.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,099.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,226.26
|
| Rate for Payer: Ohio Health Group HMO |
$2,749.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,932.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,189.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,529.68
|
| Rate for Payer: PHCS Commercial |
$3,519.55
|
| Rate for Payer: United Healthcare All Payer |
$3,226.26
|
|
|
PALATOPHARYNGOPLASTY
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 42145
|
| Hospital Charge Code |
76101674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
PALATOPHARYNGOPLASTY
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 42145
|
| Hospital Charge Code |
76101674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$790.97 |
| Max. Negotiated Rate |
$7,652.33 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,465.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,652.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,379.03
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Humana KY Medicaid |
$790.97
|
| Rate for Payer: Humana Medicare Advantage |
$5,465.95
|
| Rate for Payer: Kentucky WC Medicaid |
$799.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,559.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
PALATOPHARYNGOPLASTY
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 42145
|
| Hospital Charge Code |
76101674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$483.48 |
| Max. Negotiated Rate |
$1,380.00 |
| Rate for Payer: Aetna Commercial |
$1,006.32
|
| Rate for Payer: Ambetter Exchange |
$646.39
|
| Rate for Payer: Anthem Medicaid |
$483.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$646.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$646.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$775.67
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$977.17
|
| Rate for Payer: Healthspan PPO |
$848.65
|
| Rate for Payer: Humana Medicaid |
$483.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$907.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$646.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$646.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$493.15
|
| Rate for Payer: Molina Healthcare Passport |
$483.48
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.31
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$488.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$646.39
|
|
|
PALATOPHARYNGOPLASTY(P
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 42145
|
| Hospital Charge Code |
761P1674
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$483.48 |
| Max. Negotiated Rate |
$1,380.00 |
| Rate for Payer: Aetna Commercial |
$1,006.32
|
| Rate for Payer: Ambetter Exchange |
$646.39
|
| Rate for Payer: Anthem Medicaid |
$483.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$646.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$646.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$775.67
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$977.17
|
| Rate for Payer: Healthspan PPO |
$848.65
|
| Rate for Payer: Humana Medicaid |
$483.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$907.48
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$646.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$646.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$493.15
|
| Rate for Payer: Molina Healthcare Passport |
$483.48
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.31
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$488.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$646.39
|
|
|
PALMAZ BLUE SLALOM 4*12*135
|
Facility
|
OP
|
$7,493.66
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,248.10 |
| Max. Negotiated Rate |
$7,193.91 |
| Rate for Payer: Aetna Commercial |
$5,770.12
|
| Rate for Payer: Anthem Medicaid |
$2,577.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,845.05
|
| Rate for Payer: Cash Price |
$3,746.83
|
| Rate for Payer: Cigna Commercial |
$6,219.74
|
| Rate for Payer: First Health Commercial |
$7,118.98
|
| Rate for Payer: Humana Commercial |
$6,369.61
|
| Rate for Payer: Humana KY Medicaid |
$2,577.07
|
| Rate for Payer: Kentucky WC Medicaid |
$2,603.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,144.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,530.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,248.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,628.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,594.42
|
| Rate for Payer: Ohio Health Group HMO |
$5,620.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,994.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,519.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,170.63
|
| Rate for Payer: PHCS Commercial |
$7,193.91
|
| Rate for Payer: United Healthcare All Payer |
$6,594.42
|
|
|
PALMAZ BLUE SLALOM 4*12*135
|
Facility
|
IP
|
$7,493.66
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,248.10 |
| Max. Negotiated Rate |
$7,193.91 |
| Rate for Payer: Aetna Commercial |
$5,770.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,845.05
|
| Rate for Payer: Cash Price |
$3,746.83
|
| Rate for Payer: Cigna Commercial |
$6,219.74
|
| Rate for Payer: First Health Commercial |
$7,118.98
|
| Rate for Payer: Humana Commercial |
$6,369.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,144.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,530.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,248.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,594.42
|
| Rate for Payer: Ohio Health Group HMO |
$5,620.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,994.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,519.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,170.63
|
| Rate for Payer: PHCS Commercial |
$7,193.91
|
| Rate for Payer: United Healthcare All Payer |
$6,594.42
|
|
|
PALMAZ BLUE SLALOM 4*12*80
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 4*12*80
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 4*15*135
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 4*15*135
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
PALMAZ BLUE SLALOM 4*18*135
|
Facility
|
IP
|
$7,310.65
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,193.20 |
| Max. Negotiated Rate |
$7,018.22 |
| Rate for Payer: Aetna Commercial |
$5,629.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,702.31
|
| Rate for Payer: Cash Price |
$3,655.32
|
| Rate for Payer: Cigna Commercial |
$6,067.84
|
| Rate for Payer: First Health Commercial |
$6,945.12
|
| Rate for Payer: Humana Commercial |
$6,214.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,994.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,395.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,193.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,433.37
|
| Rate for Payer: Ohio Health Group HMO |
$5,482.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,848.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,360.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,044.35
|
| Rate for Payer: PHCS Commercial |
$7,018.22
|
| Rate for Payer: United Healthcare All Payer |
$6,433.37
|
|
