|
PRESERVATN TIB TRAY RM/LL SZ 2
|
Facility
|
OP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem Medicaid |
$3,303.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Humana KY Medicaid |
$3,303.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,337.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,369.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 2
|
Facility
|
IP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 3
|
Facility
|
IP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 3
|
Facility
|
OP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem Medicaid |
$3,303.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Humana KY Medicaid |
$3,303.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,337.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,369.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 4
|
Facility
|
OP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem Medicaid |
$3,303.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Humana KY Medicaid |
$3,303.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,337.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,369.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 4
|
Facility
|
IP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 5
|
Facility
|
IP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVATN TIB TRAY RM/LL SZ 5
|
Facility
|
OP
|
$9,606.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,248.85 |
| Max. Negotiated Rate |
$9,222.26 |
| Rate for Payer: Aetna Commercial |
$7,397.02
|
| Rate for Payer: Anthem Medicaid |
$3,303.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,493.09
|
| Rate for Payer: Cash Price |
$4,803.26
|
| Rate for Payer: Cigna Commercial |
$7,973.41
|
| Rate for Payer: First Health Commercial |
$9,126.19
|
| Rate for Payer: Humana Commercial |
$8,165.54
|
| Rate for Payer: Humana KY Medicaid |
$3,303.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,337.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,877.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,089.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,881.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,369.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,453.74
|
| Rate for Payer: Ohio Health Group HMO |
$7,204.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,921.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,978.02
|
| Rate for Payer: PHCS Commercial |
$9,222.26
|
| Rate for Payer: United Healthcare All Payer |
$8,453.74
|
|
|
PRESERVISION AREDS 2 CAP
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 24208043272
|
| Hospital Charge Code |
25003746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: United Healthcare All Payer |
$3.78
|
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
|
|
PRESERVISION AREDS 2 CAP
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 24208043272
|
| Hospital Charge Code |
25003746
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Cash Price |
$2.14
|
| Rate for Payer: Cigna Commercial |
$3.56
|
| Rate for Payer: First Health Commercial |
$4.08
|
| Rate for Payer: Humana Commercial |
$3.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.78
|
| Rate for Payer: Ohio Health Group HMO |
$3.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.33
|
| Rate for Payer: PHCS Commercial |
$4.12
|
| Rate for Payer: United Healthcare All Payer |
$3.78
|
|
|
PRESSURE TREATMENT ESOPHAGU(P
|
Professional
|
Both
|
$755.00
|
|
|
Service Code
|
HCPCS 43460
|
| Hospital Charge Code |
761P1777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.94 |
| Max. Negotiated Rate |
$755.00 |
| Rate for Payer: Aetna Commercial |
$336.67
|
| Rate for Payer: Anthem Medicaid |
$159.94
|
| 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: Cigna Commercial |
$304.37
|
| Rate for Payer: Healthspan PPO |
$283.92
|
| Rate for Payer: Humana Medicaid |
$159.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.14
|
| Rate for Payer: Molina Healthcare Passport |
$159.94
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.54
|
|
|
PRESSURE TREATMENT ESOPHAGUS
|
Professional
|
Both
|
$755.00
|
|
|
Service Code
|
HCPCS 43460
|
| Hospital Charge Code |
76101777
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$159.94 |
| Max. Negotiated Rate |
$755.00 |
| Rate for Payer: Aetna Commercial |
$336.67
|
| Rate for Payer: Anthem Medicaid |
$159.94
|
| 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: Cigna Commercial |
$304.37
|
| Rate for Payer: Healthspan PPO |
$283.92
|
| Rate for Payer: Humana Medicaid |
$159.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$163.14
|
| Rate for Payer: Molina Healthcare Passport |
$159.94
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$161.54
|
|
|
PRESSURE TREATMENT ESOPHAGUS
|
Facility
|
OP
|
$755.00
|
|
|
Service Code
|
HCPCS 43460
|
| Hospital Charge Code |
76101777
|
|
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 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: Humana KY Medicaid |
$259.64
|
| 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 |
$226.50
|
| 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
|
|
|
PRESSURE TREATMENT ESOPHAGUS
|
Facility
|
IP
|
$755.00
|
|
|
Service Code
|
HCPCS 43460
|
| Hospital Charge Code |
76101777
|
|
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
|
|
|
PRESSURE WIRE X GUIDE WIRE
|
Facility
|
OP
|
$4,450.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.56 |
| Max. Negotiated Rate |
$4,272.48 |
| Rate for Payer: Aetna Commercial |
$3,426.88
|
| Rate for Payer: Anthem Medicaid |
$1,530.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,471.39
|
| Rate for Payer: Cash Price |
$2,225.25
|
| Rate for Payer: Cigna Commercial |
$3,693.92
|
| Rate for Payer: First Health Commercial |
$4,227.98
|
| Rate for Payer: Humana Commercial |
$3,782.92
|
| Rate for Payer: Humana KY Medicaid |
$1,530.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,546.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,649.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,284.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,335.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,561.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,916.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,337.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$890.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$578.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,379.66
|
| Rate for Payer: PHCS Commercial |
$4,272.48
|
| Rate for Payer: United Healthcare All Payer |
$3,916.44
|
|
|
PRESSURE WIRE X GUIDE WIRE
|
Facility
|
IP
|
$4,450.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.56 |
| Max. Negotiated Rate |
$4,272.48 |
| Rate for Payer: Aetna Commercial |
$3,426.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,471.39
|
| Rate for Payer: Cash Price |
$2,225.25
|
| Rate for Payer: Cigna Commercial |
$3,693.92
|
| Rate for Payer: First Health Commercial |
$4,227.98
|
| Rate for Payer: Humana Commercial |
$3,782.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,649.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,284.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,335.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,916.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,337.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$890.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$578.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,379.66
|
| Rate for Payer: PHCS Commercial |
$4,272.48
|
| Rate for Payer: United Healthcare All Payer |
$3,916.44
|
|
|
PRETREAT RBC INC W CHEM AG
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
HCPCS 86970
|
| Hospital Charge Code |
30001242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$86.32
|
| Rate for Payer: First Health Commercial |
$98.80
|
| Rate for Payer: Humana Commercial |
$88.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.52
|
| Rate for Payer: Ohio Health Group HMO |
$78.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.24
|
| Rate for Payer: PHCS Commercial |
$99.84
|
| Rate for Payer: United Healthcare All Payer |
$91.52
|
|
|
PRETREAT RBC INC W CHEM AG
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
HCPCS 86970
|
| Hospital Charge Code |
30001242
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.52 |
| Max. Negotiated Rate |
$99.84 |
| Rate for Payer: Aetna Commercial |
$80.08
|
| Rate for Payer: Anthem Medicaid |
$35.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$52.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$83.51
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$74.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$71.40
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna Commercial |
$86.32
|
| Rate for Payer: First Health Commercial |
$98.80
|
| Rate for Payer: Humana Commercial |
$88.40
|
| Rate for Payer: Humana KY Medicaid |
$35.77
|
| Rate for Payer: Humana Medicare Advantage |
$52.89
|
| Rate for Payer: Kentucky WC Medicaid |
$36.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$85.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$76.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$36.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$91.52
|
| Rate for Payer: Ohio Health Group HMO |
$78.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$32.24
|
| Rate for Payer: PHCS Commercial |
$99.84
|
| Rate for Payer: United Healthcare All Payer |
$91.52
|
|
|
PRETREAT RBC W ENZYMES EACH
|
Facility
|
IP
|
$216.00
|
|
|
Service Code
|
HCPCS 86971
|
| Hospital Charge Code |
30001243
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.08 |
| Max. Negotiated Rate |
$207.36 |
| Rate for Payer: Aetna Commercial |
$166.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$173.45
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$179.28
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: Humana Commercial |
$183.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$177.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$159.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$64.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$190.08
|
| Rate for Payer: Ohio Health Group HMO |
$162.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.96
|
| Rate for Payer: PHCS Commercial |
$207.36
|
| Rate for Payer: United Healthcare All Payer |
$190.08
|
|
|
PRETREAT RBC W ENZYMES EACH
|
Facility
|
OP
|
$216.00
|
|
|
Service Code
|
HCPCS 86971
|
| Hospital Charge Code |
30001243
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.08 |
| Max. Negotiated Rate |
$207.36 |
| Rate for Payer: Aetna Commercial |
$166.32
|
| Rate for Payer: Anthem Medicaid |
$74.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$147.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$173.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$206.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$199.40
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cash Price |
$108.00
|
| Rate for Payer: Cigna Commercial |
$179.28
|
| Rate for Payer: First Health Commercial |
$205.20
|
| Rate for Payer: Humana Commercial |
$183.60
|
| Rate for Payer: Humana KY Medicaid |
$74.28
|
| Rate for Payer: Humana Medicare Advantage |
$147.70
|
| Rate for Payer: Kentucky WC Medicaid |
$75.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$177.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$159.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$75.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$190.08
|
| Rate for Payer: Ohio Health Group HMO |
$162.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$43.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.96
|
| Rate for Payer: PHCS Commercial |
$207.36
|
| Rate for Payer: United Healthcare All Payer |
$190.08
|
|
|
PREVACID (LANSOPRAZO 15MG/1CAP
|
Facility
|
OP
|
$5.05
|
|
|
Service Code
|
NDC 68001011104
|
| Hospital Charge Code |
25001224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Anthem Medicaid |
$1.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.19
|
| Rate for Payer: First Health Commercial |
$4.80
|
| Rate for Payer: Humana Commercial |
$4.29
|
| Rate for Payer: Humana KY Medicaid |
$1.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.85
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
PREVACID (LANSOPRAZO 15MG/1CAP
|
Facility
|
IP
|
$5.05
|
|
|
Service Code
|
NDC 68001011104
|
| Hospital Charge Code |
25001224
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$4.85 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.94
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.19
|
| Rate for Payer: First Health Commercial |
$4.80
|
| Rate for Payer: Humana Commercial |
$4.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.57
|
| Rate for Payer: PHCS Commercial |
$4.85
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
|
PREVACID (LANSOPRAZO 30MG/1TAB
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 16571069803
|
| Hospital Charge Code |
25001225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| 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 |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
|
|
PREVACID (LANSOPRAZO 30MG/1TAB
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 16571069803
|
| Hospital Charge Code |
25001225
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| 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 |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
PREVENA PEEL & PLACE SYSTEM
|
Facility
|
IP
|
$3,932.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$511.22 |
| Max. Negotiated Rate |
$3,775.20 |
| Rate for Payer: Aetna Commercial |
$3,028.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,067.35
|
| Rate for Payer: Cash Price |
$1,966.25
|
| Rate for Payer: Cigna Commercial |
$3,263.98
|
| Rate for Payer: First Health Commercial |
$3,735.88
|
| Rate for Payer: Humana Commercial |
$3,342.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,224.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,902.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,179.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,460.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,949.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$786.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$511.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,219.08
|
| Rate for Payer: PHCS Commercial |
$3,775.20
|
| Rate for Payer: United Healthcare All Payer |
$3,460.60
|
|
