|
REF XLPE ALL POLY CUP 36 55
|
Facility
|
IP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 55
|
Facility
|
OP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem Medicaid |
$2,635.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Humana KY Medicaid |
$2,635.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,662.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,688.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 58
|
Facility
|
IP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 58
|
Facility
|
OP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem Medicaid |
$2,635.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Humana KY Medicaid |
$2,635.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,662.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,688.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 61
|
Facility
|
OP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem Medicaid |
$2,635.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Humana KY Medicaid |
$2,635.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,662.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,688.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 61
|
Facility
|
IP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 64
|
Facility
|
OP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem Medicaid |
$2,635.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Humana KY Medicaid |
$2,635.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,662.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,688.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP 36 64
|
Facility
|
IP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP SZ 61MM
|
Facility
|
IP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REF XLPE ALL POLY CUP SZ 61MM
|
Facility
|
OP
|
$7,664.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$996.41 |
| Max. Negotiated Rate |
$7,358.13 |
| Rate for Payer: Aetna Commercial |
$5,901.83
|
| Rate for Payer: Anthem Medicaid |
$2,635.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,978.48
|
| Rate for Payer: Cash Price |
$3,832.36
|
| Rate for Payer: Cigna Commercial |
$6,361.72
|
| Rate for Payer: First Health Commercial |
$7,281.48
|
| Rate for Payer: Humana Commercial |
$6,515.01
|
| Rate for Payer: Humana KY Medicaid |
$2,635.90
|
| Rate for Payer: Kentucky WC Medicaid |
$2,662.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,285.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,656.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,299.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,688.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,744.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,748.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,532.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$996.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,376.06
|
| Rate for Payer: PHCS Commercial |
$7,358.13
|
| Rate for Payer: United Healthcare All Payer |
$6,744.95
|
|
|
REFYNE
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200026
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
REGALIA XS 1.0 GW 180CM
|
Facility
|
IP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
REGALIA XS 1.0 GW 180CM
|
Facility
|
OP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem Medicaid |
$662.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Humana KY Medicaid |
$662.87
|
| Rate for Payer: Kentucky WC Medicaid |
$669.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$676.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
REGALIA XS 1.0 GW 300CM
|
Facility
|
IP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
REGALIA XS 1.0 GW 300CM
|
Facility
|
OP
|
$1,927.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$250.58 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna Commercial |
$1,484.18
|
| Rate for Payer: Anthem Medicaid |
$662.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.45
|
| Rate for Payer: Cash Price |
$963.75
|
| Rate for Payer: Cigna Commercial |
$1,599.82
|
| Rate for Payer: First Health Commercial |
$1,831.12
|
| Rate for Payer: Humana Commercial |
$1,638.38
|
| Rate for Payer: Humana KY Medicaid |
$662.87
|
| Rate for Payer: Kentucky WC Medicaid |
$669.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$676.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,696.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$385.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$250.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$597.52
|
| Rate for Payer: PHCS Commercial |
$1,850.40
|
| Rate for Payer: United Healthcare All Payer |
$1,696.20
|
|
|
REGITINE (PHENTOLAMINE 5MG/1ML
|
Facility
|
IP
|
$2,287.91
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
25002334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.43 |
| Max. Negotiated Rate |
$2,196.39 |
| Rate for Payer: Aetna Commercial |
$1,761.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,784.57
|
| Rate for Payer: Cash Price |
$1,143.95
|
| Rate for Payer: Cigna Commercial |
$1,898.97
|
| Rate for Payer: First Health Commercial |
$2,173.51
|
| Rate for Payer: Humana Commercial |
$1,944.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,876.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,688.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$686.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,013.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,715.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$297.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$709.25
|
| Rate for Payer: PHCS Commercial |
$2,196.39
|
| Rate for Payer: United Healthcare All Payer |
$2,013.36
|
|
|
REGITINE (PHENTOLAMINE 5MG/1ML
|
Facility
|
OP
|
$2,287.91
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
25002334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$297.43 |
| Max. Negotiated Rate |
$2,196.39 |
| Rate for Payer: Aetna Commercial |
$1,761.69
|
| Rate for Payer: Anthem Medicaid |
$786.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$446.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,784.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$625.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$603.18
|
| Rate for Payer: Cash Price |
$1,143.95
|
| Rate for Payer: Cash Price |
$1,143.95
|
| Rate for Payer: Cigna Commercial |
$1,898.97
|
| Rate for Payer: First Health Commercial |
$2,173.51
|
| Rate for Payer: Humana Commercial |
$1,944.72
|
| Rate for Payer: Humana KY Medicaid |
$786.81
|
| Rate for Payer: Humana Medicare Advantage |
$446.80
|
| Rate for Payer: Kentucky WC Medicaid |
$794.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,876.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,688.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$536.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$802.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,013.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,715.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$457.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$297.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$709.25
|
| Rate for Payer: PHCS Commercial |
$2,196.39
|
| Rate for Payer: United Healthcare All Payer |
$2,013.36
|
|
|
REGLAN (METOCLOPR) 1 10MG/10ML
|
Facility
|
IP
|
$4.82
|
|
|
Service Code
|
NDC 121057616
|
| Hospital Charge Code |
25001294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Cash Price |
$2.41
|
| Rate for Payer: Cigna Commercial |
$4.00
|
| Rate for Payer: First Health Commercial |
$4.58
|
| Rate for Payer: Humana Commercial |
$4.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.24
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
|
REGLAN (METOCLOPR) 1 10MG/10ML
|
Facility
|
OP
|
$4.82
|
|
|
Service Code
|
NDC 121057616
|
| Hospital Charge Code |
25001294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.63 |
| Rate for Payer: Aetna Commercial |
$3.71
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.76
|
| Rate for Payer: Cash Price |
$2.41
|
| Rate for Payer: Cigna Commercial |
$4.00
|
| Rate for Payer: First Health Commercial |
$4.58
|
| Rate for Payer: Humana Commercial |
$4.10
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.24
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
|
REGLAN (METOCLOPRAMI 10MG/1TAB
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 60687063101
|
| Hospital Charge Code |
25001295
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
REGLAN (METOCLOPRAMI 10MG/1TAB
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 60687063101
|
| Hospital Charge Code |
25001295
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
REGLAN (METOCLOPRAMID 5MG/1TAB
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 60687062001
|
| Hospital Charge Code |
25001296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
REGLAN (METOCLOPRAMID 5MG/1TAB
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 60687062001
|
| Hospital Charge Code |
25001296
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
OP
|
$74.13
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
636T0056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$71.16 |
| Rate for Payer: Aetna Commercial |
$57.08
|
| Rate for Payer: Anthem Medicaid |
$25.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cigna Commercial |
$61.53
|
| Rate for Payer: First Health Commercial |
$70.42
|
| Rate for Payer: Humana Commercial |
$63.01
|
| Rate for Payer: Humana KY Medicaid |
$25.49
|
| Rate for Payer: Kentucky WC Medicaid |
$25.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.23
|
| Rate for Payer: Ohio Health Group HMO |
$55.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.98
|
| Rate for Payer: PHCS Commercial |
$71.16
|
| Rate for Payer: United Healthcare All Payer |
$65.23
|
|
|
REGLAN(METOCLOPRAMIDE 10MG/2ML
|
Facility
|
IP
|
$74.13
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
63600056
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$71.16 |
| Rate for Payer: Aetna Commercial |
$57.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cigna Commercial |
$61.53
|
| Rate for Payer: First Health Commercial |
$70.42
|
| Rate for Payer: Humana Commercial |
$63.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$65.23
|
| Rate for Payer: Ohio Health Group HMO |
$55.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.98
|
| Rate for Payer: PHCS Commercial |
$71.16
|
| Rate for Payer: United Healthcare All Payer |
$65.23
|
|
