|
POTELIGEO 1mg (20mg Vial)
|
Facility
|
OP
|
$25,051.96
|
|
|
Service Code
|
HCPCS J9204
|
| Hospital Charge Code |
25004051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$234.16 |
| Max. Negotiated Rate |
$24,049.88 |
| Rate for Payer: Aetna Commercial |
$19,290.01
|
| Rate for Payer: Anthem Medicaid |
$8,615.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$234.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,540.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$327.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$316.12
|
| Rate for Payer: Cash Price |
$12,525.98
|
| Rate for Payer: Cash Price |
$12,525.98
|
| Rate for Payer: Cigna Commercial |
$20,793.13
|
| Rate for Payer: First Health Commercial |
$23,799.36
|
| Rate for Payer: Humana Commercial |
$21,294.17
|
| Rate for Payer: Humana KY Medicaid |
$8,615.37
|
| Rate for Payer: Humana Medicare Advantage |
$234.16
|
| Rate for Payer: Kentucky WC Medicaid |
$8,703.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,542.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,488.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$281.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,788.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,045.72
|
| Rate for Payer: Ohio Health Group HMO |
$18,788.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,010.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,256.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,766.11
|
| Rate for Payer: PHCS Commercial |
$24,049.88
|
| Rate for Payer: United Healthcare All Payer |
$22,045.72
|
|
|
POTELIGEO 1mg (20mg Vial)
|
Facility
|
IP
|
$25,051.96
|
|
|
Service Code
|
HCPCS J9204
|
| Hospital Charge Code |
25004051
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,256.75 |
| Max. Negotiated Rate |
$24,049.88 |
| Rate for Payer: Aetna Commercial |
$19,290.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,540.53
|
| Rate for Payer: Cash Price |
$12,525.98
|
| Rate for Payer: Cigna Commercial |
$20,793.13
|
| Rate for Payer: First Health Commercial |
$23,799.36
|
| Rate for Payer: Humana Commercial |
$21,294.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,542.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,488.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,515.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,045.72
|
| Rate for Payer: Ohio Health Group HMO |
$18,788.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,010.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,256.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,766.11
|
| Rate for Payer: PHCS Commercial |
$24,049.88
|
| Rate for Payer: United Healthcare All Payer |
$22,045.72
|
|
|
POWERCROSS .018 PTA 5*150*150
|
Facility
|
IP
|
$2,085.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
POWERCROSS .018 PTA 5*150*150
|
Facility
|
OP
|
$2,085.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem Medicaid |
$717.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Humana KY Medicaid |
$717.03
|
| Rate for Payer: Kentucky WC Medicaid |
$724.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$731.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
POWERCROSS .018 PTA 5*200*150
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
POWERCROSS .018 PTA 5*200*150
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
POWERCROSS .018 PTA 5*80*150
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
POWERCROSS .018 PTA 5*80*150
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
POWERCROSS .018 PTA 6*150*150
|
Facility
|
IP
|
$2,085.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
POWERCROSS .018 PTA 6*150*150
|
Facility
|
OP
|
$2,085.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem Medicaid |
$717.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Humana KY Medicaid |
$717.03
|
| Rate for Payer: Kentucky WC Medicaid |
$724.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$731.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
POWERCROSS .018 PTA 6*200*150
|
Facility
|
IP
|
$2,085.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
POWERCROSS .018 PTA 6*200*150
|
Facility
|
OP
|
$2,085.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$271.05 |
| Max. Negotiated Rate |
$2,001.60 |
| Rate for Payer: Aetna Commercial |
$1,605.45
|
| Rate for Payer: Anthem Medicaid |
$717.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,626.30
|
| Rate for Payer: Cash Price |
$1,042.50
|
| Rate for Payer: Cigna Commercial |
$1,730.55
|
| Rate for Payer: First Health Commercial |
$1,980.75
|
| Rate for Payer: Humana Commercial |
$1,772.25
|
| Rate for Payer: Humana KY Medicaid |
$717.03
|
| Rate for Payer: Kentucky WC Medicaid |
$724.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,709.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,538.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$625.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$731.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,834.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,563.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$417.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$271.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$646.35
|
| Rate for Payer: PHCS Commercial |
$2,001.60
|
| Rate for Payer: United Healthcare All Payer |
$1,834.80
|
|
|
POWERCROSS .018 PTA 6*80*150
|
Facility
|
IP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
POWERCROSS .018 PTA 6*80*150
|
Facility
|
OP
|
$1,980.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$1,900.80 |
| Rate for Payer: Aetna Commercial |
$1,524.60
|
| Rate for Payer: Anthem Medicaid |
$680.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,544.40
|
| Rate for Payer: Cash Price |
$990.00
|
| Rate for Payer: Cigna Commercial |
$1,643.40
|
| Rate for Payer: First Health Commercial |
$1,881.00
|
| Rate for Payer: Humana Commercial |
$1,683.00
|
| Rate for Payer: Humana KY Medicaid |
$680.92
|
| Rate for Payer: Kentucky WC Medicaid |
$687.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,623.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,461.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$594.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$694.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,742.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,485.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$396.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$257.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$613.80
|
| Rate for Payer: PHCS Commercial |
$1,900.80
|
| Rate for Payer: United Healthcare All Payer |
$1,742.40
|
|
|
POWERFLOW APHERESIS PORT 9.6F
|
Facility
|
IP
|
$6,555.85
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$852.26 |
| Max. Negotiated Rate |
$6,293.62 |
| Rate for Payer: Aetna Commercial |
$5,048.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,113.56
|
| Rate for Payer: Cash Price |
$3,277.93
|
| Rate for Payer: Cigna Commercial |
$5,441.36
|
| Rate for Payer: First Health Commercial |
$6,228.06
|
| Rate for Payer: Humana Commercial |
$5,572.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,375.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,838.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,966.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,769.15
|
| Rate for Payer: Ohio Health Group HMO |
$4,916.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,311.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$852.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,032.31
|
| Rate for Payer: PHCS Commercial |
$6,293.62
|
| Rate for Payer: United Healthcare All Payer |
$5,769.15
|
|
|
POWERFLOW APHERESIS PORT 9.6F
|
Facility
|
OP
|
$6,555.85
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$852.26 |
| Max. Negotiated Rate |
$6,293.62 |
| Rate for Payer: Aetna Commercial |
$5,048.00
|
| Rate for Payer: Anthem Medicaid |
$2,254.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,113.56
|
| Rate for Payer: Cash Price |
$3,277.93
|
| Rate for Payer: Cigna Commercial |
$5,441.36
|
| Rate for Payer: First Health Commercial |
$6,228.06
|
| Rate for Payer: Humana Commercial |
$5,572.47
|
| Rate for Payer: Humana KY Medicaid |
$2,254.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,277.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,375.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,838.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,966.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,299.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,769.15
|
| Rate for Payer: Ohio Health Group HMO |
$4,916.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,311.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$852.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,032.31
|
| Rate for Payer: PHCS Commercial |
$6,293.62
|
| Rate for Payer: United Healthcare All Payer |
$5,769.15
|
|
|
POWERPORT 6.6F
|
Facility
|
IP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
POWERPORT 6.6F
|
Facility
|
OP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem Medicaid |
$647.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Humana KY Medicaid |
$647.22
|
| Rate for Payer: Kentucky WC Medicaid |
$653.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
POWERPORT 8F
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
POWERPORT 8F
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
PPIL VAG DEL
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 58605
|
| Hospital Charge Code |
76102245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
PPIL VAG DEL
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 58605
|
| Hospital Charge Code |
76102245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$497.61
|
| Rate for Payer: Anthem Medicaid |
$234.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$490.00
|
| Rate for Payer: Healthspan PPO |
$481.82
|
| Rate for Payer: Humana Medicaid |
$234.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$426.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.68
|
| Rate for Payer: Molina Healthcare Passport |
$234.00
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.34
|
|
|
PPIL VAG DEL
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 58605
|
| Hospital Charge Code |
76102245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
PPIL VAG DEL(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 58605
|
| Hospital Charge Code |
761P2245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$497.61
|
| Rate for Payer: Anthem Medicaid |
$234.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$490.00
|
| Rate for Payer: Healthspan PPO |
$481.82
|
| Rate for Payer: Humana Medicaid |
$234.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$426.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$238.68
|
| Rate for Payer: Molina Healthcare Passport |
$234.00
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$236.34
|
|
|
PPPS, SUBSEQ VISIT
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS G0439
|
| Hospital Charge Code |
50000189
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Aetna Commercial |
$168.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$260.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Cash Price |
$130.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$142.04
|
| Rate for Payer: Multiplan PHCS |
$156.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$182.00
|
| Rate for Payer: UHCCP Medicaid |
$91.00
|
|
