|
PLATE Y PROFYLE M COMP REG 7H
|
Facility
|
OP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem Medicaid |
$1,363.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Humana KY Medicaid |
$1,363.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,377.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,390.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE Y PROFYLE M COMP REG 7H
|
Facility
|
IP
|
$3,964.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$515.32 |
| Max. Negotiated Rate |
$3,805.44 |
| Rate for Payer: Aetna Commercial |
$3,052.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,091.92
|
| Rate for Payer: Cash Price |
$1,982.00
|
| Rate for Payer: Cigna Commercial |
$3,290.12
|
| Rate for Payer: First Health Commercial |
$3,765.80
|
| Rate for Payer: Humana Commercial |
$3,369.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,250.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,925.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,189.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,488.32
|
| Rate for Payer: Ohio Health Group HMO |
$2,973.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$792.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.84
|
| Rate for Payer: PHCS Commercial |
$3,805.44
|
| Rate for Payer: United Healthcare All Payer |
$3,488.32
|
|
|
PLATE Y PROFYLE NARROW 5H
|
Facility
|
OP
|
$3,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$478.92 |
| Max. Negotiated Rate |
$3,536.64 |
| Rate for Payer: Aetna Commercial |
$2,836.68
|
| Rate for Payer: Anthem Medicaid |
$1,266.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,873.52
|
| Rate for Payer: Cash Price |
$1,842.00
|
| Rate for Payer: Cigna Commercial |
$3,057.72
|
| Rate for Payer: First Health Commercial |
$3,499.80
|
| Rate for Payer: Humana Commercial |
$3,131.40
|
| Rate for Payer: Humana KY Medicaid |
$1,266.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,279.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,020.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,718.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,105.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,292.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,241.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,763.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.04
|
| Rate for Payer: PHCS Commercial |
$3,536.64
|
| Rate for Payer: United Healthcare All Payer |
$3,241.92
|
|
|
PLATE Y PROFYLE NARROW 5H
|
Facility
|
IP
|
$3,684.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$478.92 |
| Max. Negotiated Rate |
$3,536.64 |
| Rate for Payer: Aetna Commercial |
$2,836.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,873.52
|
| Rate for Payer: Cash Price |
$1,842.00
|
| Rate for Payer: Cigna Commercial |
$3,057.72
|
| Rate for Payer: First Health Commercial |
$3,499.80
|
| Rate for Payer: Humana Commercial |
$3,131.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,020.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,718.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,105.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,241.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,763.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$736.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$478.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,142.04
|
| Rate for Payer: PHCS Commercial |
$3,536.64
|
| Rate for Payer: United Healthcare All Payer |
$3,241.92
|
|
|
PLATE Y PROFYL LOCK 2.3 NAR 7H
|
Facility
|
OP
|
$3,663.24
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$476.22 |
| Max. Negotiated Rate |
$3,516.71 |
| Rate for Payer: Aetna Commercial |
$2,820.69
|
| Rate for Payer: Anthem Medicaid |
$1,259.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,857.33
|
| Rate for Payer: Cash Price |
$1,831.62
|
| Rate for Payer: Cigna Commercial |
$3,040.49
|
| Rate for Payer: First Health Commercial |
$3,480.08
|
| Rate for Payer: Humana Commercial |
$3,113.75
|
| Rate for Payer: Humana KY Medicaid |
$1,259.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,272.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,003.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,703.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,098.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,285.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,223.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,747.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$732.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,135.60
|
| Rate for Payer: PHCS Commercial |
$3,516.71
|
| Rate for Payer: United Healthcare All Payer |
$3,223.65
|
|
|
PLATE Y PROFYL LOCK 2.3 NAR 7H
|
Facility
|
IP
|
$3,663.24
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$476.22 |
| Max. Negotiated Rate |
$3,516.71 |
| Rate for Payer: Aetna Commercial |
$2,820.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,857.33
|
| Rate for Payer: Cash Price |
$1,831.62
|
| Rate for Payer: Cigna Commercial |
$3,040.49
|
| Rate for Payer: First Health Commercial |
$3,480.08
|
| Rate for Payer: Humana Commercial |
$3,113.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,003.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,703.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,098.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,223.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,747.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$732.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,135.60
|
| Rate for Payer: PHCS Commercial |
$3,516.71
|
| Rate for Payer: United Healthcare All Payer |
$3,223.65
|
|
|
PLATE Z PROFYLE 2.3 13H
|
Facility
|
IP
|
$3,759.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$488.75 |
| Max. Negotiated Rate |
$3,609.22 |
| Rate for Payer: Aetna Commercial |
$2,894.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,879.80
|
| Rate for Payer: Cigna Commercial |
$3,120.47
|
| Rate for Payer: First Health Commercial |
$3,571.62
|
| Rate for Payer: Humana Commercial |
$3,195.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,082.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,774.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,127.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,308.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,819.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$751.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$488.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,165.48
|
| Rate for Payer: PHCS Commercial |
$3,609.22
|
| Rate for Payer: United Healthcare All Payer |
$3,308.45
|
|
|
PLATE Z PROFYLE 2.3 13H
|
Facility
|
OP
|
$3,759.60
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$488.75 |
| Max. Negotiated Rate |
$3,609.22 |
| Rate for Payer: Anthem Medicaid |
$1,292.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,932.49
|
| Rate for Payer: Cash Price |
$1,879.80
|
| Rate for Payer: Cigna Commercial |
$3,120.47
|
| Rate for Payer: First Health Commercial |
$3,571.62
|
| Rate for Payer: Humana Commercial |
$3,195.66
|
| Rate for Payer: Humana KY Medicaid |
$1,292.93
|
| Rate for Payer: Kentucky WC Medicaid |
$1,306.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,082.87
|
| Rate for Payer: Aetna Commercial |
$2,894.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,774.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,127.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,318.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,308.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,819.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$751.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$488.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,165.48
|
| Rate for Payer: PHCS Commercial |
$3,609.22
|
| Rate for Payer: United Healthcare All Payer |
$3,308.45
|
|
|
PLATE Z PROFYLE LCK NAR 1.7 9H
|
Facility
|
IP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE Z PROFYLE LCK NAR 1.7 9H
|
Facility
|
OP
|
$4,941.20
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$642.36 |
| Max. Negotiated Rate |
$4,743.55 |
| Rate for Payer: Aetna Commercial |
$3,804.72
|
| Rate for Payer: Anthem Medicaid |
$1,699.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,854.14
|
| Rate for Payer: Cash Price |
$2,470.60
|
| Rate for Payer: Cigna Commercial |
$4,101.20
|
| Rate for Payer: First Health Commercial |
$4,694.14
|
| Rate for Payer: Humana Commercial |
$4,200.02
|
| Rate for Payer: Humana KY Medicaid |
$1,699.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,716.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,051.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,646.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,733.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,348.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,705.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,531.77
|
| Rate for Payer: PHCS Commercial |
$4,743.55
|
| Rate for Payer: United Healthcare All Payer |
$4,348.26
|
|
|
PLATE Z PROFYL LCK 2.3 NAR 13H
|
Facility
|
OP
|
$4,497.36
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.66 |
| Max. Negotiated Rate |
$4,317.47 |
| Rate for Payer: Aetna Commercial |
$3,462.97
|
| Rate for Payer: Anthem Medicaid |
$1,546.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,507.94
|
| Rate for Payer: Cash Price |
$2,248.68
|
| Rate for Payer: Cigna Commercial |
$3,732.81
|
| Rate for Payer: First Health Commercial |
$4,272.49
|
| Rate for Payer: Humana Commercial |
$3,822.76
|
| Rate for Payer: Humana KY Medicaid |
$1,546.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,562.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,687.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,319.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,349.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,577.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,957.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,373.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$899.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$584.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,394.18
|
| Rate for Payer: PHCS Commercial |
$4,317.47
|
| Rate for Payer: United Healthcare All Payer |
$3,957.68
|
|
|
PLATE Z PROFYL LCK 2.3 NAR 13H
|
Facility
|
IP
|
$4,497.36
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$584.66 |
| Max. Negotiated Rate |
$4,317.47 |
| Rate for Payer: Aetna Commercial |
$3,462.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,507.94
|
| Rate for Payer: Cash Price |
$2,248.68
|
| Rate for Payer: Cigna Commercial |
$3,732.81
|
| Rate for Payer: First Health Commercial |
$4,272.49
|
| Rate for Payer: Humana Commercial |
$3,822.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,687.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,319.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,349.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,957.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,373.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$899.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$584.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,394.18
|
| Rate for Payer: PHCS Commercial |
$4,317.47
|
| Rate for Payer: United Healthcare All Payer |
$3,957.68
|
|
|
PLAT SAG SPLT CVD 6H 6M BARLCK
|
Facility
|
IP
|
$3,178.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$413.20 |
| Max. Negotiated Rate |
$3,051.36 |
| Rate for Payer: Aetna Commercial |
$2,447.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,479.23
|
| Rate for Payer: Cash Price |
$1,589.25
|
| Rate for Payer: Cigna Commercial |
$2,638.16
|
| Rate for Payer: First Health Commercial |
$3,019.58
|
| Rate for Payer: Humana Commercial |
$2,701.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,606.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,345.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$953.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,797.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,383.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$635.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$985.34
|
| Rate for Payer: PHCS Commercial |
$3,051.36
|
| Rate for Payer: United Healthcare All Payer |
$2,797.08
|
|
|
PLAT SAG SPLT CVD 6H 6M BARLCK
|
Facility
|
OP
|
$3,178.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$413.20 |
| Max. Negotiated Rate |
$3,051.36 |
| Rate for Payer: Aetna Commercial |
$2,447.44
|
| Rate for Payer: Anthem Medicaid |
$1,093.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,479.23
|
| Rate for Payer: Cash Price |
$1,589.25
|
| Rate for Payer: Cigna Commercial |
$2,638.16
|
| Rate for Payer: First Health Commercial |
$3,019.58
|
| Rate for Payer: Humana Commercial |
$2,701.72
|
| Rate for Payer: Humana KY Medicaid |
$1,093.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,104.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,606.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,345.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$953.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,115.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,797.08
|
| Rate for Payer: Ohio Health Group HMO |
$2,383.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$635.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$985.34
|
| Rate for Payer: PHCS Commercial |
$3,051.36
|
| Rate for Payer: United Healthcare All Payer |
$2,797.08
|
|
|
PLAVIX (CLOPIDOGREL)75MG TAB
|
Facility
|
IP
|
$4.46
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
25001191
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
|
|
PLAVIX (CLOPIDOGREL)75MG TAB
|
Facility
|
OP
|
$4.46
|
|
|
Service Code
|
NDC 68084053601
|
| Hospital Charge Code |
25001191
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Humana Commercial |
$3.79
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.92
|
| Rate for Payer: Ohio Health Group HMO |
$3.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.38
|
| Rate for Payer: PHCS Commercial |
$4.28
|
| Rate for Payer: United Healthcare All Payer |
$3.92
|
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.48
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.70
|
| Rate for Payer: First Health Commercial |
$4.24
|
|
|
PLAY AUDIO
|
Professional
|
Both
|
$347.00
|
|
|
Service Code
|
HCPCS 92582
|
| Hospital Charge Code |
47000038
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.95 |
| Max. Negotiated Rate |
$347.00 |
| Rate for Payer: Aetna Commercial |
$61.01
|
| Rate for Payer: Anthem Medicaid |
$10.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$347.00
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cigna Commercial |
$49.91
|
| Rate for Payer: Healthspan PPO |
$49.92
|
| Rate for Payer: Humana Medicaid |
$10.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$58.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$11.17
|
| Rate for Payer: Molina Healthcare Passport |
$10.95
|
| Rate for Payer: Multiplan PHCS |
$208.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$242.90
|
| Rate for Payer: UHCCP Medicaid |
$121.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.06
|
|
|
PLAY AUDIO
|
Facility
|
OP
|
$347.00
|
|
|
Service Code
|
HCPCS 92582
|
| Hospital Charge Code |
47000038
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$45.11 |
| Max. Negotiated Rate |
$333.12 |
| Rate for Payer: Aetna Commercial |
$267.19
|
| Rate for Payer: Anthem Medicaid |
$119.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$270.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cigna Commercial |
$288.01
|
| Rate for Payer: First Health Commercial |
$329.65
|
| Rate for Payer: Humana Commercial |
$294.95
|
| Rate for Payer: Humana KY Medicaid |
$119.33
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$120.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$284.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$256.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$121.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$305.36
|
| Rate for Payer: Ohio Health Group HMO |
$260.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.57
|
| Rate for Payer: PHCS Commercial |
$333.12
|
| Rate for Payer: United Healthcare All Payer |
$305.36
|
|
|
PLAY AUDIO
|
Facility
|
IP
|
$347.00
|
|
|
Service Code
|
HCPCS 92582
|
| Hospital Charge Code |
47000038
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$45.11 |
| Max. Negotiated Rate |
$333.12 |
| Rate for Payer: Aetna Commercial |
$267.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$270.66
|
| Rate for Payer: Cash Price |
$173.50
|
| Rate for Payer: Cigna Commercial |
$288.01
|
| Rate for Payer: First Health Commercial |
$329.65
|
| Rate for Payer: Humana Commercial |
$294.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$284.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$256.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$305.36
|
| Rate for Payer: Ohio Health Group HMO |
$260.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.57
|
| Rate for Payer: PHCS Commercial |
$333.12
|
| Rate for Payer: United Healthcare All Payer |
$305.36
|
|
|
PLAY AUDIO(P
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 92582
|
| Hospital Charge Code |
470P0038
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$10.95 |
| Max. Negotiated Rate |
$61.01 |
| Rate for Payer: Aetna Commercial |
$61.01
|
| Rate for Payer: Anthem Medicaid |
$10.95
|
| Rate for Payer: Buckeye Medicare Advantage |
$60.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.91
|
| Rate for Payer: Healthspan PPO |
$49.92
|
| Rate for Payer: Humana Medicaid |
$10.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$58.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$11.17
|
| Rate for Payer: Molina Healthcare Passport |
$10.95
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$42.00
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.06
|
|
|
PLAY AUDIO(T
|
Facility
|
IP
|
$287.00
|
|
|
Service Code
|
HCPCS 92582
|
| Hospital Charge Code |
470T0038
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$86.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.97
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
PLAY AUDIO(T
|
Facility
|
OP
|
$287.00
|
|
|
Service Code
|
HCPCS 92582
|
| Hospital Charge Code |
470T0038
|
|
Hospital Revenue Code
|
470
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$275.52 |
| Rate for Payer: Aetna Commercial |
$220.99
|
| Rate for Payer: Anthem Medicaid |
$98.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$223.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: Cigna Commercial |
$238.21
|
| Rate for Payer: First Health Commercial |
$272.65
|
| Rate for Payer: Humana Commercial |
$243.95
|
| Rate for Payer: Humana KY Medicaid |
$98.70
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$99.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$235.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$211.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$100.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$252.56
|
| Rate for Payer: Ohio Health Group HMO |
$215.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$37.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$88.97
|
| Rate for Payer: PHCS Commercial |
$275.52
|
| Rate for Payer: United Healthcare All Payer |
$252.56
|
|
|
PLCMENT BAKRI TAMPONADE BALLOO
|
Professional
|
Both
|
$755.00
|
|
|
Service Code
|
HCPCS 59899
|
| Hospital Charge Code |
76102859
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$755.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$755.00
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$453.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$528.50
|
| Rate for Payer: UHCCP Medicaid |
$264.25
|
|
|
PLCMENT BAKRI TAMPONADE BALLOO
|
Facility
|
IP
|
$755.00
|
|
|
Service Code
|
HCPCS 59899
|
| Hospital Charge Code |
76102859
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.15 |
| Max. Negotiated Rate |
$724.80 |
| Rate for Payer: Aetna Commercial |
$581.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$588.90
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cigna Commercial |
$626.65
|
| Rate for Payer: First Health Commercial |
$717.25
|
| Rate for Payer: Humana Commercial |
$641.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$619.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$557.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$226.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$664.40
|
| Rate for Payer: Ohio Health Group HMO |
$566.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.05
|
| Rate for Payer: PHCS Commercial |
$724.80
|
| Rate for Payer: United Healthcare All Payer |
$664.40
|
|
|
PLCMENT BAKRI TAMPONADE BALLOO
|
Facility
|
OP
|
$755.00
|
|
|
Service Code
|
HCPCS 59899
|
| Hospital Charge Code |
76102859
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.15 |
| Max. Negotiated Rate |
$724.80 |
| Rate for Payer: Aetna Commercial |
$581.35
|
| Rate for Payer: Anthem Medicaid |
$259.64
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$172.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$588.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$241.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$232.63
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cash Price |
$377.50
|
| Rate for Payer: Cigna Commercial |
$626.65
|
| Rate for Payer: First Health Commercial |
$717.25
|
| Rate for Payer: Humana Commercial |
$641.75
|
| Rate for Payer: Humana KY Medicaid |
$259.64
|
| Rate for Payer: Humana Medicare Advantage |
$172.32
|
| Rate for Payer: Kentucky WC Medicaid |
$262.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$619.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$557.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$206.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$264.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$664.40
|
| Rate for Payer: Ohio Health Group HMO |
$566.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$151.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$98.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$234.05
|
| Rate for Payer: PHCS Commercial |
$724.80
|
| Rate for Payer: United Healthcare All Payer |
$664.40
|
|
