|
AP SKSB T/A/L ADTL25CM HC
|
Facility
|
OP
|
$433.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
76100191
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.90 |
| Max. Negotiated Rate |
$415.68 |
| Rate for Payer: Aetna Commercial |
$333.41
|
| Rate for Payer: Anthem Medicaid |
$148.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$337.74
|
| Rate for Payer: Cash Price |
$216.50
|
| Rate for Payer: Cigna Commercial |
$359.39
|
| Rate for Payer: First Health Commercial |
$411.35
|
| Rate for Payer: Humana Commercial |
$368.05
|
| Rate for Payer: Humana KY Medicaid |
$148.91
|
| Rate for Payer: Kentucky WC Medicaid |
$150.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$355.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$319.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$129.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$151.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$381.04
|
| Rate for Payer: Ohio Health Group HMO |
$324.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$346.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$298.77
|
| Rate for Payer: PHCS Commercial |
$415.68
|
| Rate for Payer: United Healthcare All Payer |
$381.04
|
|
|
AP SKSB T/A/L ADTL25CM HC(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
761P0191
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Ambetter Exchange |
$15.84
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$9.00
|
| Rate for Payer: Anthem Medicaid |
$21.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$15.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$15.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.01
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$29.49
|
| Rate for Payer: Healthspan PPO |
$24.55
|
| Rate for Payer: Humana Medicaid |
$21.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$21.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$15.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$21.94
|
| Rate for Payer: Molina Healthcare Passport |
$21.51
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$20.59
|
| Rate for Payer: UHCCP Medicaid |
$9.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$15.84
|
|
|
AP SKSB T/A/L ADTL25CM HC(T
|
Facility
|
OP
|
$183.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
761T0191
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.90 |
| Max. Negotiated Rate |
$175.68 |
| Rate for Payer: Aetna Commercial |
$140.91
|
| Rate for Payer: Anthem Medicaid |
$62.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.74
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$151.89
|
| Rate for Payer: First Health Commercial |
$173.85
|
| Rate for Payer: Humana Commercial |
$155.55
|
| Rate for Payer: Humana KY Medicaid |
$62.93
|
| Rate for Payer: Kentucky WC Medicaid |
$63.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.04
|
| Rate for Payer: Ohio Health Group HMO |
$137.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$146.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.27
|
| Rate for Payer: PHCS Commercial |
$175.68
|
| Rate for Payer: United Healthcare All Payer |
$161.04
|
|
|
AP SKSB T/A/L ADTL25CM HC(T
|
Facility
|
IP
|
$183.00
|
|
|
Service Code
|
HCPCS 15272
|
| Hospital Charge Code |
761T0191
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.90 |
| Max. Negotiated Rate |
$175.68 |
| Rate for Payer: Aetna Commercial |
$140.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$142.74
|
| Rate for Payer: Cash Price |
$91.50
|
| Rate for Payer: Cigna Commercial |
$151.89
|
| Rate for Payer: First Health Commercial |
$173.85
|
| Rate for Payer: Humana Commercial |
$155.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.04
|
| Rate for Payer: Ohio Health Group HMO |
$137.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$146.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$159.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$126.27
|
| Rate for Payer: PHCS Commercial |
$175.68
|
| Rate for Payer: United Healthcare All Payer |
$161.04
|
|
|
AQMBF PET REST & RX STRESS
|
Facility
|
OP
|
$4,282.00
|
|
|
Service Code
|
HCPCS 78434
|
| Hospital Charge Code |
404T0005
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,284.60 |
| Max. Negotiated Rate |
$4,110.72 |
| Rate for Payer: Aetna Commercial |
$3,297.14
|
| Rate for Payer: Anthem Medicaid |
$1,472.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,339.96
|
| Rate for Payer: Cash Price |
$2,141.00
|
| Rate for Payer: Cigna Commercial |
$3,554.06
|
| Rate for Payer: First Health Commercial |
$4,067.90
|
| Rate for Payer: Humana Commercial |
$3,639.70
|
| Rate for Payer: Humana KY Medicaid |
$1,472.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,487.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,511.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,160.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,284.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,502.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,768.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,211.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,425.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,725.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,954.58
|
| Rate for Payer: PHCS Commercial |
$4,110.72
|
| Rate for Payer: United Healthcare All Payer |
$3,768.16
|
|
|
AQMBF PET REST & RX STRESS
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 78434
|
| Hospital Charge Code |
404P0005
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$35.27 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Cash Price |
$115.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.27
|
| Rate for Payer: Multiplan PHCS |
$138.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$161.00
|
| Rate for Payer: UHCCP Medicaid |
$80.50
|
|
|
AQMBF PET REST & RX STRESS
|
Facility
|
IP
|
$4,282.00
|
|
|
Service Code
|
HCPCS 78434
|
| Hospital Charge Code |
404T0005
|
|
Hospital Revenue Code
|
404
|
| Min. Negotiated Rate |
$1,284.60 |
| Max. Negotiated Rate |
$4,110.72 |
| Rate for Payer: Aetna Commercial |
$3,297.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,339.96
|
| Rate for Payer: Cash Price |
$2,141.00
|
| Rate for Payer: Cigna Commercial |
$3,554.06
|
| Rate for Payer: First Health Commercial |
$4,067.90
|
| Rate for Payer: Humana Commercial |
$3,639.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,511.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,160.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,284.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,768.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,211.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,425.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,725.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,954.58
|
| Rate for Payer: PHCS Commercial |
$4,110.72
|
| Rate for Payer: United Healthcare All Payer |
$3,768.16
|
|
|
AQUABEAM DRAPE PACK
|
Facility
|
IP
|
$1,946.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$583.80 |
| Max. Negotiated Rate |
$1,868.16 |
| Rate for Payer: Aetna Commercial |
$1,498.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.88
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cigna Commercial |
$1,615.18
|
| Rate for Payer: First Health Commercial |
$1,848.70
|
| Rate for Payer: Humana Commercial |
$1,654.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,595.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,436.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,712.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,459.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,556.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,693.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,342.74
|
| Rate for Payer: PHCS Commercial |
$1,868.16
|
| Rate for Payer: United Healthcare All Payer |
$1,712.48
|
|
|
AQUABEAM DRAPE PACK
|
Facility
|
OP
|
$1,946.00
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$583.80 |
| Max. Negotiated Rate |
$1,868.16 |
| Rate for Payer: Aetna Commercial |
$1,498.42
|
| Rate for Payer: Anthem Medicaid |
$669.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,517.88
|
| Rate for Payer: Cash Price |
$973.00
|
| Rate for Payer: Cigna Commercial |
$1,615.18
|
| Rate for Payer: First Health Commercial |
$1,848.70
|
| Rate for Payer: Humana Commercial |
$1,654.10
|
| Rate for Payer: Humana KY Medicaid |
$669.23
|
| Rate for Payer: Kentucky WC Medicaid |
$676.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,595.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,436.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$583.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$682.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,712.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,459.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,556.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,693.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,342.74
|
| Rate for Payer: PHCS Commercial |
$1,868.16
|
| Rate for Payer: United Healthcare All Payer |
$1,712.48
|
|
|
AQUABEAM HANDPIECE
|
Facility
|
IP
|
$16,425.00
|
|
|
Service Code
|
HCPCS C2596
|
| Hospital Charge Code |
27000277
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,927.50 |
| Max. Negotiated Rate |
$15,768.00 |
| Rate for Payer: Aetna Commercial |
$12,647.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.50
|
| Rate for Payer: Cash Price |
$8,212.50
|
| Rate for Payer: Cigna Commercial |
$13,632.75
|
| Rate for Payer: First Health Commercial |
$15,603.75
|
| Rate for Payer: Humana Commercial |
$13,961.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,121.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,289.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,333.25
|
| Rate for Payer: PHCS Commercial |
$15,768.00
|
| Rate for Payer: United Healthcare All Payer |
$14,454.00
|
|
|
AQUABEAM HANDPIECE
|
Facility
|
OP
|
$16,425.00
|
|
|
Service Code
|
HCPCS C2596
|
| Hospital Charge Code |
27000277
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,927.50 |
| Max. Negotiated Rate |
$15,768.00 |
| Rate for Payer: Aetna Commercial |
$12,647.25
|
| Rate for Payer: Anthem Medicaid |
$5,648.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,811.50
|
| Rate for Payer: Cash Price |
$8,212.50
|
| Rate for Payer: Cigna Commercial |
$13,632.75
|
| Rate for Payer: First Health Commercial |
$15,603.75
|
| Rate for Payer: Humana Commercial |
$13,961.25
|
| Rate for Payer: Humana KY Medicaid |
$5,648.56
|
| Rate for Payer: Kentucky WC Medicaid |
$5,706.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,468.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,121.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,927.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,761.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,454.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,289.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,333.25
|
| Rate for Payer: PHCS Commercial |
$15,768.00
|
| Rate for Payer: United Healthcare All Payer |
$14,454.00
|
|
|
AQUA MEPHYTON (PHYTON) 1 MG
|
Facility
|
OP
|
$204.97
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.49 |
| Max. Negotiated Rate |
$196.77 |
| Rate for Payer: Aetna Commercial |
$157.83
|
| Rate for Payer: Anthem Medicaid |
$70.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.88
|
| Rate for Payer: Cash Price |
$102.48
|
| Rate for Payer: Cigna Commercial |
$170.13
|
| Rate for Payer: First Health Commercial |
$194.72
|
| Rate for Payer: Humana Commercial |
$174.22
|
| Rate for Payer: Humana KY Medicaid |
$70.49
|
| Rate for Payer: Kentucky WC Medicaid |
$71.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$71.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.37
|
| Rate for Payer: Ohio Health Group HMO |
$153.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.43
|
| Rate for Payer: PHCS Commercial |
$196.77
|
| Rate for Payer: United Healthcare All Payer |
$180.37
|
|
|
AQUA MEPHYTON (PHYTON) 1 MG
|
Facility
|
IP
|
$204.97
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.49 |
| Max. Negotiated Rate |
$196.77 |
| Rate for Payer: Aetna Commercial |
$157.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$159.88
|
| Rate for Payer: Cash Price |
$102.48
|
| Rate for Payer: Cigna Commercial |
$170.13
|
| Rate for Payer: First Health Commercial |
$194.72
|
| Rate for Payer: Humana Commercial |
$174.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$168.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$151.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$180.37
|
| Rate for Payer: Ohio Health Group HMO |
$153.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$178.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$141.43
|
| Rate for Payer: PHCS Commercial |
$196.77
|
| Rate for Payer: United Healthcare All Payer |
$180.37
|
|
|
AQUA MEPHYTON(PHYTONA 1MG/.5ML
|
Facility
|
IP
|
$80.75
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.23 |
| Max. Negotiated Rate |
$77.52 |
| Rate for Payer: Aetna Commercial |
$62.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.98
|
| Rate for Payer: Cash Price |
$40.38
|
| Rate for Payer: Cigna Commercial |
$67.02
|
| Rate for Payer: First Health Commercial |
$76.71
|
| Rate for Payer: Humana Commercial |
$68.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.06
|
| Rate for Payer: Ohio Health Group HMO |
$60.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.72
|
| Rate for Payer: PHCS Commercial |
$77.52
|
| Rate for Payer: United Healthcare All Payer |
$71.06
|
|
|
AQUA MEPHYTON(PHYTONA 1MG/.5ML
|
Facility
|
OP
|
$80.75
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
25002428
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.23 |
| Max. Negotiated Rate |
$77.52 |
| Rate for Payer: Aetna Commercial |
$62.18
|
| Rate for Payer: Anthem Medicaid |
$27.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.98
|
| Rate for Payer: Cash Price |
$40.38
|
| Rate for Payer: Cigna Commercial |
$67.02
|
| Rate for Payer: First Health Commercial |
$76.71
|
| Rate for Payer: Humana Commercial |
$68.64
|
| Rate for Payer: Humana KY Medicaid |
$27.77
|
| Rate for Payer: Kentucky WC Medicaid |
$28.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$71.06
|
| Rate for Payer: Ohio Health Group HMO |
$60.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$64.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$55.72
|
| Rate for Payer: PHCS Commercial |
$77.52
|
| Rate for Payer: United Healthcare All Payer |
$71.06
|
|
|
AQUAPHOR 85APPLIC/85G
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 72140063377
|
| Hospital Charge Code |
25004565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna Commercial |
$0.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.07
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.07
|
| Rate for Payer: First Health Commercial |
$0.09
|
| Rate for Payer: Humana Commercial |
$0.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.08
|
| Rate for Payer: Ohio Health Group HMO |
$0.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Payer |
$0.08
|
|
|
AQUAPHOR 85APPLIC/85G
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 72140063377
|
| Hospital Charge Code |
25004565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna Commercial |
$0.07
|
| Rate for Payer: Anthem Medicaid |
$0.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.07
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna Commercial |
$0.07
|
| Rate for Payer: First Health Commercial |
$0.09
|
| Rate for Payer: Humana Commercial |
$0.08
|
| Rate for Payer: Humana KY Medicaid |
$0.03
|
| Rate for Payer: Kentucky WC Medicaid |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.08
|
| Rate for Payer: Ohio Health Group HMO |
$0.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Payer |
$0.08
|
|
|
AQUATIC THERAPY - 15 MIN 1
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 97113
|
| Hospital Charge Code |
43000014
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem Medicaid |
$46.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$105.30
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Humana KY Medicaid |
$46.43
|
| Rate for Payer: Kentucky WC Medicaid |
$46.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.15
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
AQUATIC THERAPY - 15 MIN 1
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 97113
|
| Hospital Charge Code |
43000014
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$129.60 |
| Rate for Payer: Aetna Commercial |
$103.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$105.30
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna Commercial |
$112.05
|
| Rate for Payer: First Health Commercial |
$128.25
|
| Rate for Payer: Humana Commercial |
$114.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$110.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$99.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$118.80
|
| Rate for Payer: Ohio Health Group HMO |
$101.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.15
|
| Rate for Payer: PHCS Commercial |
$129.60
|
| Rate for Payer: United Healthcare All Payer |
$118.80
|
|
|
AQUATIC THERAPY-15 MIN 1
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS 97113
|
| Hospital Charge Code |
42000019
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem Medicaid |
$49.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.32
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Humana KY Medicaid |
$49.52
|
| Rate for Payer: Kentucky WC Medicaid |
$50.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
AQUATIC THERAPY-15 MIN 1
|
Facility
|
IP
|
$144.00
|
|
|
Service Code
|
HCPCS 97113
|
| Hospital Charge Code |
42000019
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$43.20 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.32
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$125.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$99.36
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
|
AR1 GUIDE 5F
|
Facility
|
OP
|
$795.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem Medicaid |
$273.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Humana KY Medicaid |
$273.40
|
| Rate for Payer: Kentucky WC Medicaid |
$276.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
AR1 GUIDE 5F
|
Facility
|
IP
|
$795.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$238.50 |
| Max. Negotiated Rate |
$763.20 |
| Rate for Payer: Aetna Commercial |
$612.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.10
|
| Rate for Payer: Cash Price |
$397.50
|
| Rate for Payer: Cigna Commercial |
$659.85
|
| Rate for Payer: First Health Commercial |
$755.25
|
| Rate for Payer: Humana Commercial |
$675.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$651.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.60
|
| Rate for Payer: Ohio Health Group HMO |
$596.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$691.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$548.55
|
| Rate for Payer: PHCS Commercial |
$763.20
|
| Rate for Payer: United Healthcare All Payer |
$699.60
|
|
|
AR 1 GUIDE CATH 8FR
|
Facility
|
OP
|
$1,115.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$334.50 |
| Max. Negotiated Rate |
$1,070.40 |
| Rate for Payer: Aetna Commercial |
$858.55
|
| Rate for Payer: Anthem Medicaid |
$383.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$869.70
|
| Rate for Payer: Cash Price |
$557.50
|
| Rate for Payer: Cigna Commercial |
$925.45
|
| Rate for Payer: First Health Commercial |
$1,059.25
|
| Rate for Payer: Humana Commercial |
$947.75
|
| Rate for Payer: Humana KY Medicaid |
$383.45
|
| Rate for Payer: Kentucky WC Medicaid |
$387.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$914.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$822.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$334.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$391.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$981.20
|
| Rate for Payer: Ohio Health Group HMO |
$836.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$892.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$970.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$769.35
|
| Rate for Payer: PHCS Commercial |
$1,070.40
|
| Rate for Payer: United Healthcare All Payer |
$981.20
|
|
|
AR 1 GUIDE CATH 8FR
|
Facility
|
IP
|
$1,115.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$334.50 |
| Max. Negotiated Rate |
$1,070.40 |
| Rate for Payer: Aetna Commercial |
$858.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$869.70
|
| Rate for Payer: Cash Price |
$557.50
|
| Rate for Payer: Cigna Commercial |
$925.45
|
| Rate for Payer: First Health Commercial |
$1,059.25
|
| Rate for Payer: Humana Commercial |
$947.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$914.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$822.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$334.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$981.20
|
| Rate for Payer: Ohio Health Group HMO |
$836.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$892.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$970.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$769.35
|
| Rate for Payer: PHCS Commercial |
$1,070.40
|
| Rate for Payer: United Healthcare All Payer |
$981.20
|
|
