|
REF XLPE ALL POLY CUP 36 52
|
Facility
|
OP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem Medicaid |
$2,704.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Humana KY Medicaid |
$2,704.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,732.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,758.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 52
|
Facility
|
IP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 55
|
Facility
|
IP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 55
|
Facility
|
OP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem Medicaid |
$2,704.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Humana KY Medicaid |
$2,704.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,732.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,758.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 58
|
Facility
|
OP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem Medicaid |
$2,704.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Humana KY Medicaid |
$2,704.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,732.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,758.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 58
|
Facility
|
IP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 61
|
Facility
|
IP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 61
|
Facility
|
OP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem Medicaid |
$2,704.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Humana KY Medicaid |
$2,704.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,732.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,758.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 64
|
Facility
|
IP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP 36 64
|
Facility
|
OP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem Medicaid |
$2,704.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Humana KY Medicaid |
$2,704.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,732.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,758.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP SZ 61MM
|
Facility
|
IP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REF XLPE ALL POLY CUP SZ 61MM
|
Facility
|
OP
|
$7,864.72
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,359.42 |
| Max. Negotiated Rate |
$7,550.13 |
| Rate for Payer: Aetna Commercial |
$6,055.83
|
| Rate for Payer: Anthem Medicaid |
$2,704.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,134.48
|
| Rate for Payer: Cash Price |
$3,932.36
|
| Rate for Payer: Cigna Commercial |
$6,527.72
|
| Rate for Payer: First Health Commercial |
$7,471.48
|
| Rate for Payer: Humana Commercial |
$6,685.01
|
| Rate for Payer: Humana KY Medicaid |
$2,704.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,732.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,449.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,804.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,359.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,758.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,920.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,898.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,291.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,842.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,426.66
|
| Rate for Payer: PHCS Commercial |
$7,550.13
|
| Rate for Payer: United Healthcare All Payer |
$6,920.95
|
|
|
REFYNE
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
22200026
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
REFYNE
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
22200026
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
REFYNE
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200026
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$420.00 |
| 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
|
OP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.10 |
| Max. Negotiated Rate |
$1,849.92 |
| Rate for Payer: Aetna Commercial |
$1,483.79
|
| Rate for Payer: Anthem Medicaid |
$662.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.06
|
| Rate for Payer: Cash Price |
$963.50
|
| Rate for Payer: Cigna Commercial |
$1,599.41
|
| Rate for Payer: First Health Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial |
$1,637.95
|
| Rate for Payer: Humana KY Medicaid |
$662.70
|
| Rate for Payer: Kentucky WC Medicaid |
$669.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$675.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,695.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,541.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,676.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,329.63
|
| Rate for Payer: PHCS Commercial |
$1,849.92
|
| Rate for Payer: United Healthcare All Payer |
$1,695.76
|
|
|
REGALIA XS 1.0 GW 180CM
|
Facility
|
IP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.10 |
| Max. Negotiated Rate |
$1,849.92 |
| Rate for Payer: Aetna Commercial |
$1,483.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.06
|
| Rate for Payer: Cash Price |
$963.50
|
| Rate for Payer: Cigna Commercial |
$1,599.41
|
| Rate for Payer: First Health Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,695.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,541.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,676.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,329.63
|
| Rate for Payer: PHCS Commercial |
$1,849.92
|
| Rate for Payer: United Healthcare All Payer |
$1,695.76
|
|
|
REGALIA XS 1.0 GW 300CM
|
Facility
|
IP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.10 |
| Max. Negotiated Rate |
$1,849.92 |
| Rate for Payer: Aetna Commercial |
$1,483.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.06
|
| Rate for Payer: Cash Price |
$963.50
|
| Rate for Payer: Cigna Commercial |
$1,599.41
|
| Rate for Payer: First Health Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial |
$1,637.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,695.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,541.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,676.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,329.63
|
| Rate for Payer: PHCS Commercial |
$1,849.92
|
| Rate for Payer: United Healthcare All Payer |
$1,695.76
|
|
|
REGALIA XS 1.0 GW 300CM
|
Facility
|
OP
|
$1,927.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$578.10 |
| Max. Negotiated Rate |
$1,849.92 |
| Rate for Payer: Aetna Commercial |
$1,483.79
|
| Rate for Payer: Anthem Medicaid |
$662.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,503.06
|
| Rate for Payer: Cash Price |
$963.50
|
| Rate for Payer: Cigna Commercial |
$1,599.41
|
| Rate for Payer: First Health Commercial |
$1,830.65
|
| Rate for Payer: Humana Commercial |
$1,637.95
|
| Rate for Payer: Humana KY Medicaid |
$662.70
|
| Rate for Payer: Kentucky WC Medicaid |
$669.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,580.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,422.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$578.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$675.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,695.76
|
| Rate for Payer: Ohio Health Group HMO |
$1,445.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,541.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,676.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,329.63
|
| Rate for Payer: PHCS Commercial |
$1,849.92
|
| Rate for Payer: United Healthcare All Payer |
$1,695.76
|
|
|
REGITINE (PHENTOLAMINE 5MG/1ML
|
Facility
|
IP
|
$2,287.91
|
|
|
Service Code
|
HCPCS J2760
|
| Hospital Charge Code |
25002334
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$686.37 |
| 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 |
$1,830.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,990.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,578.66
|
| 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 |
$436.51 |
| 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 |
$436.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,784.57
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$611.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$589.29
|
| 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 |
$436.51
|
| 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 |
$523.81
|
| 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 |
$1,830.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,990.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,578.66
|
| Rate for Payer: PHCS Commercial |
$2,196.39
|
| Rate for Payer: United Healthcare All Payer |
$2,013.36
|
|
|
REGLAN (METOCLOPR) 1 10MG/10ML
|
Facility
|
OP
|
$4.82
|
|
|
Service Code
|
NDC 121057616
|
| Hospital Charge Code |
25001294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| 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 |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$4.63
|
| Rate for Payer: United Healthcare All Payer |
$4.24
|
|
|
REGLAN (METOCLOPR) 1 10MG/10ML
|
Facility
|
IP
|
$4.82
|
|
|
Service Code
|
NDC 121057616
|
| Hospital Charge Code |
25001294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| 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 |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| 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 |
$1.44 |
| 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 |
$3.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| 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 |
$1.44 |
| 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 |
$3.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
