|
REF HA 3H SZ 54MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 56MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 56MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 58MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 58MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 60MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 60MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 62MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 62MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 64MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF HA 3H SZ 64MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REFILL CHEMO MAINTE PORT PUMP
|
Facility
|
OP
|
$229.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
33100011
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$78.75 |
| Max. Negotiated Rate |
$272.54 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$194.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$272.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$262.80
|
| 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 |
$194.67
|
| 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 |
$233.60
|
| 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 |
$183.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$199.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.01
|
| Rate for Payer: PHCS Commercial |
$219.84
|
| Rate for Payer: United Healthcare All Payer |
$201.52
|
|
|
REFILL CHEMO MAINTE PORT PUMP
|
Facility
|
IP
|
$229.00
|
|
|
Service Code
|
HCPCS 96521
|
| Hospital Charge Code |
33100011
|
|
Hospital Revenue Code
|
335
|
| Min. Negotiated Rate |
$68.70 |
| 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 |
$183.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$199.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.01
|
| 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 |
$78.75 |
| Max. Negotiated Rate |
$272.54 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$194.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$272.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$262.80
|
| 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 |
$194.67
|
| 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 |
$233.60
|
| 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 |
$183.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$199.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.01
|
| 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 |
$68.70 |
| 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 |
$183.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$199.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.01
|
| 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 |
$78.75 |
| Max. Negotiated Rate |
$272.54 |
| Rate for Payer: Aetna Commercial |
$176.33
|
| Rate for Payer: Anthem Medicaid |
$78.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$194.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$178.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$272.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$262.80
|
| 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 |
$194.67
|
| 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 |
$233.60
|
| 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 |
$183.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$199.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.01
|
| 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 |
$68.70 |
| 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 |
$183.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$199.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.01
|
| 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
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 46-48OD ANT+4 SZD
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 50-52OD ANT+4 SZE
|
Facility
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 50-52OD ANT+4 SZE
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 54-56OD ANT+4 SZF
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 54-56OD ANT+4 SZF
|
Facility
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 58-60OD ANT+4 SZG
|
Facility
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 58-60OD ANT+4 SZG
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
