|
REF HA 3H SZ 56MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 58MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 58MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 60MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 60MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 62MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 62MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 64MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF HA 3H SZ 64MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REFILL CHEMO MAINTE PORT PUMP
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
33100011
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$219.84 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REFILL CHEMO MAINTE PORT PUMP
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
33100011
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$259.49 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$185.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$259.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$250.22
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Humana KY Medicaid |
$78.75
|
| Rate for Payer: Humana Medicare Advantage |
$185.35
|
| Rate for Payer: Kentucky WC Medicaid |
$79.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REFILL MAINT IMPLANTED PUMP
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
HCPCS 96522
|
| Hospital Charge Code |
94000006
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$219.84 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REFILL MAINT IMPLANTED PUMP
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
HCPCS 96522
|
| Hospital Charge Code |
94000006
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$259.49 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$185.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$259.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$250.22
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Humana KY Medicaid |
$78.75
|
| Rate for Payer: Humana Medicare Advantage |
$185.35
|
| Rate for Payer: Kentucky WC Medicaid |
$79.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REFILL MAINT PORTABLE PUMP
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
94000005
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$259.49 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$185.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$259.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$250.22
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Humana KY Medicaid |
$78.75
|
| Rate for Payer: Humana Medicare Advantage |
$185.35
|
| Rate for Payer: Kentucky WC Medicaid |
$79.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$222.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$80.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REFILL MAINT PORTABLE PUMP
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
94000005
|
|
Hospital Revenue Code
|
940
|
| Min. Negotiated Rate |
$29.77 |
| Max. Negotiated Rate |
$219.84 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Cash Price |
$114.50
|
| Rate for Payer: Cigna Commercial |
$190.07
|
| Rate for Payer: First Health Commercial |
$217.55
|
| Rate for Payer: Humana Commercial |
$194.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$187.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$169.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$201.52
|
| Rate for Payer: Ohio Health Group HMO |
$171.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$70.99
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REF INR 28ID 46-48OD ANT+4 SZD
|
Facility
|
IP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 46-48OD ANT+4 SZD
|
Facility
|
OP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem Medicaid |
$1,689.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Humana KY Medicaid |
$1,689.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 50-52OD ANT+4 SZE
|
Facility
|
OP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem Medicaid |
$1,689.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Humana KY Medicaid |
$1,689.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 50-52OD ANT+4 SZE
|
Facility
|
IP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 54-56OD ANT+4 SZF
|
Facility
|
OP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem Medicaid |
$1,689.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Humana KY Medicaid |
$1,689.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 54-56OD ANT+4 SZF
|
Facility
|
IP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 58-60OD ANT+4 SZG
|
Facility
|
OP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem Medicaid |
$1,689.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Humana KY Medicaid |
$1,689.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 58-60OD ANT+4 SZG
|
Facility
|
IP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 62-64OD ANT+4 SZH
|
Facility
|
OP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem Medicaid |
$1,689.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Humana KY Medicaid |
$1,689.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
|
REF INR 28ID 62-64OD ANT+4 SZH
|
Facility
|
IP
|
$4,913.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$638.72 |
| Max. Negotiated Rate |
$4,716.67 |
| Rate for Payer: Aetna Commercial |
$3,783.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,832.30
|
| Rate for Payer: Cash Price |
$2,456.60
|
| Rate for Payer: Cigna Commercial |
$4,077.96
|
| Rate for Payer: First Health Commercial |
$4,667.54
|
| Rate for Payer: Humana Commercial |
$4,176.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,523.09
|
| Rate for Payer: PHCS Commercial |
$4,716.67
|
| Rate for Payer: United Healthcare All Payer |
$4,323.62
|
|
