|
RESOLUTE ONYX 5.0*15
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOLUTE ONYX 5.0*18
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
RESOLUTE ONYX 5.0*18
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
RESOLUTE ONYX 5.0*22
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOLUTE ONYX 5.0*22
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOLUTE ONYX 5.0*26
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOLUTE ONYX 5.0*26
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOLUTE ONYX 5.0*30
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOLUTE ONYX 5.0*30
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
RESOURCE 7 GRAM (PER SCOOP)
|
Facility
|
IP
|
$4.84
|
|
|
Service Code
|
NDC 43900028430
|
| Hospital Charge Code |
25001318
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.02
|
| Rate for Payer: First Health Commercial |
$4.60
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.26
|
| Rate for Payer: Ohio Health Group HMO |
$3.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Payer |
$4.26
|
|
|
RESOURCE 7 GRAM (PER SCOOP)
|
Facility
|
OP
|
$4.84
|
|
|
Service Code
|
NDC 43900028430
|
| Hospital Charge Code |
25001318
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.02
|
| Rate for Payer: First Health Commercial |
$4.60
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.26
|
| Rate for Payer: Ohio Health Group HMO |
$3.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$4.65
|
| Rate for Payer: United Healthcare All Payer |
$4.26
|
|
|
RESPIRATORY FLOW VOLUME
|
Facility
|
OP
|
$497.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
41000103
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$170.92 |
| Max. Negotiated Rate |
$477.12 |
| Rate for Payer: Aetna Commercial |
$382.69
|
| Rate for Payer: Anthem Medicaid |
$170.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$387.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cigna Commercial |
$412.51
|
| Rate for Payer: First Health Commercial |
$472.15
|
| Rate for Payer: Humana Commercial |
$422.45
|
| Rate for Payer: Humana KY Medicaid |
$170.92
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$172.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$407.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$366.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$174.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$437.36
|
| Rate for Payer: Ohio Health Group HMO |
$372.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$397.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$432.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.93
|
| Rate for Payer: PHCS Commercial |
$477.12
|
| Rate for Payer: United Healthcare All Payer |
$437.36
|
|
|
RESPIRATORY FLOW VOLUME
|
Professional
|
Both
|
$497.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
41000103
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$298.20 |
| Rate for Payer: Aetna Commercial |
$56.43
|
| Rate for Payer: Ambetter Exchange |
$35.45
|
| Rate for Payer: Anthem Medicaid |
$28.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.54
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cigna Commercial |
$52.98
|
| Rate for Payer: Healthspan PPO |
$43.71
|
| Rate for Payer: Humana Medicaid |
$28.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$18.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.60
|
| Rate for Payer: Molina Healthcare Passport |
$28.04
|
| Rate for Payer: Multiplan PHCS |
$298.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.09
|
| Rate for Payer: UHCCP Medicaid |
$173.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.45
|
|
|
RESPIRATORY FLOW VOLUME
|
Facility
|
IP
|
$497.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
41000103
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$149.10 |
| Max. Negotiated Rate |
$477.12 |
| Rate for Payer: Aetna Commercial |
$382.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$387.66
|
| Rate for Payer: Cash Price |
$248.50
|
| Rate for Payer: Cigna Commercial |
$412.51
|
| Rate for Payer: First Health Commercial |
$472.15
|
| Rate for Payer: Humana Commercial |
$422.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$407.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$366.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$149.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$437.36
|
| Rate for Payer: Ohio Health Group HMO |
$372.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$397.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$432.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.93
|
| Rate for Payer: PHCS Commercial |
$477.12
|
| Rate for Payer: United Healthcare All Payer |
$437.36
|
|
|
RESPIRATORY FLOW VOLUME(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
410P0103
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$56.43
|
| Rate for Payer: Ambetter Exchange |
$35.45
|
| Rate for Payer: Anthem Medicaid |
$28.04
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.45
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.54
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$52.98
|
| Rate for Payer: Healthspan PPO |
$43.71
|
| Rate for Payer: Humana Medicaid |
$28.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$18.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$28.60
|
| Rate for Payer: Molina Healthcare Passport |
$28.04
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.09
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$28.32
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.45
|
|
|
RESPIRATORY FLOW VOLUME(T
|
Facility
|
IP
|
$397.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
410T0103
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$119.10 |
| Max. Negotiated Rate |
$381.12 |
| Rate for Payer: Aetna Commercial |
$305.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$309.66
|
| Rate for Payer: Cash Price |
$198.50
|
| Rate for Payer: Cigna Commercial |
$329.51
|
| Rate for Payer: First Health Commercial |
$377.15
|
| Rate for Payer: Humana Commercial |
$337.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$325.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$292.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$119.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$349.36
|
| Rate for Payer: Ohio Health Group HMO |
$297.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$317.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$345.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$273.93
|
| Rate for Payer: PHCS Commercial |
$381.12
|
| Rate for Payer: United Healthcare All Payer |
$349.36
|
|
|
RESPIRATORY FLOW VOLUME(T
|
Facility
|
OP
|
$397.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
410T0103
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$136.53 |
| Max. Negotiated Rate |
$402.82 |
| Rate for Payer: Aetna Commercial |
$305.69
|
| Rate for Payer: Anthem Medicaid |
$136.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$287.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$309.66
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$402.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$388.44
|
| Rate for Payer: Cash Price |
$198.50
|
| Rate for Payer: Cash Price |
$198.50
|
| Rate for Payer: Cigna Commercial |
$329.51
|
| Rate for Payer: First Health Commercial |
$377.15
|
| Rate for Payer: Humana Commercial |
$337.45
|
| Rate for Payer: Humana KY Medicaid |
$136.53
|
| Rate for Payer: Humana Medicare Advantage |
$287.73
|
| Rate for Payer: Kentucky WC Medicaid |
$137.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$325.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$292.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$139.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$349.36
|
| Rate for Payer: Ohio Health Group HMO |
$297.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$317.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$345.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$273.93
|
| Rate for Payer: PHCS Commercial |
$381.12
|
| Rate for Payer: United Healthcare All Payer |
$349.36
|
|
|
RESPIRATORY MOTION MANAGEMEN(P
|
Professional
|
Both
|
$215.00
|
|
|
Service Code
|
HCPCS 77293
|
| Hospital Charge Code |
333P0004
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$75.25 |
| Max. Negotiated Rate |
$671.71 |
| Rate for Payer: Ambetter Exchange |
$362.12
|
| Rate for Payer: Anthem Medicaid |
$319.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$362.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$362.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$434.54
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cash Price |
$107.50
|
| Rate for Payer: Cigna Commercial |
$671.71
|
| Rate for Payer: Healthspan PPO |
$547.25
|
| Rate for Payer: Humana Medicaid |
$319.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$362.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$362.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$325.94
|
| Rate for Payer: Molina Healthcare Passport |
$319.55
|
| Rate for Payer: Multiplan PHCS |
$129.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$470.76
|
| Rate for Payer: UHCCP Medicaid |
$75.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$322.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$362.12
|
|
|
RESPIRATORY MOTION MANAGEMEN(T
|
Facility
|
IP
|
$694.00
|
|
|
Service Code
|
HCPCS 77293
|
| Hospital Charge Code |
333T0004
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$208.20 |
| Max. Negotiated Rate |
$666.24 |
| Rate for Payer: Aetna Commercial |
$534.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$541.32
|
| Rate for Payer: Cash Price |
$347.00
|
| Rate for Payer: Cigna Commercial |
$576.02
|
| Rate for Payer: First Health Commercial |
$659.30
|
| Rate for Payer: Humana Commercial |
$589.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$569.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$512.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$208.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$610.72
|
| Rate for Payer: Ohio Health Group HMO |
$520.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$555.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$603.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$478.86
|
| Rate for Payer: PHCS Commercial |
$666.24
|
| Rate for Payer: United Healthcare All Payer |
$610.72
|
|
|
RESPIRATORY MOTION MANAGEMEN(T
|
Facility
|
OP
|
$694.00
|
|
|
Service Code
|
HCPCS 77293
|
| Hospital Charge Code |
333T0004
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$208.20 |
| Max. Negotiated Rate |
$666.24 |
| Rate for Payer: Aetna Commercial |
$534.38
|
| Rate for Payer: Anthem Medicaid |
$238.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$541.32
|
| Rate for Payer: Cash Price |
$347.00
|
| Rate for Payer: Cigna Commercial |
$576.02
|
| Rate for Payer: First Health Commercial |
$659.30
|
| Rate for Payer: Humana Commercial |
$589.90
|
| Rate for Payer: Humana KY Medicaid |
$238.67
|
| Rate for Payer: Kentucky WC Medicaid |
$241.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$569.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$512.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$208.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$243.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$610.72
|
| Rate for Payer: Ohio Health Group HMO |
$520.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$555.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$603.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$478.86
|
| Rate for Payer: PHCS Commercial |
$666.24
|
| Rate for Payer: United Healthcare All Payer |
$610.72
|
|
|
RESPIRATORY MOTION MANAGEMENT
|
Facility
|
IP
|
$909.00
|
|
|
Service Code
|
HCPCS 77293
|
| Hospital Charge Code |
33300004
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$272.70 |
| Max. Negotiated Rate |
$872.64 |
| Rate for Payer: Aetna Commercial |
$699.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.02
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cigna Commercial |
$754.47
|
| Rate for Payer: First Health Commercial |
$863.55
|
| Rate for Payer: Humana Commercial |
$772.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$745.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$670.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$272.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$799.92
|
| Rate for Payer: Ohio Health Group HMO |
$681.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$790.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.21
|
| Rate for Payer: PHCS Commercial |
$872.64
|
| Rate for Payer: United Healthcare All Payer |
$799.92
|
|
|
RESPIRATORY MOTION MANAGEMENT
|
Facility
|
OP
|
$909.00
|
|
|
Service Code
|
HCPCS 77293
|
| Hospital Charge Code |
33300004
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$272.70 |
| Max. Negotiated Rate |
$872.64 |
| Rate for Payer: Aetna Commercial |
$699.93
|
| Rate for Payer: Anthem Medicaid |
$312.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$709.02
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cigna Commercial |
$754.47
|
| Rate for Payer: First Health Commercial |
$863.55
|
| Rate for Payer: Humana Commercial |
$772.65
|
| Rate for Payer: Humana KY Medicaid |
$312.61
|
| Rate for Payer: Kentucky WC Medicaid |
$315.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$745.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$670.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$272.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$318.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$799.92
|
| Rate for Payer: Ohio Health Group HMO |
$681.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$790.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$627.21
|
| Rate for Payer: PHCS Commercial |
$872.64
|
| Rate for Payer: United Healthcare All Payer |
$799.92
|
|
|
RESPIRATORY MOTION MANAGEMENT
|
Professional
|
Both
|
$909.00
|
|
|
Service Code
|
HCPCS 77293
|
| Hospital Charge Code |
33300004
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$130.31 |
| Max. Negotiated Rate |
$671.71 |
| Rate for Payer: Ambetter Exchange |
$362.12
|
| Rate for Payer: Anthem Medicaid |
$319.55
|
| Rate for Payer: Buckeye Individual/Medicaid |
$362.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$362.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$434.54
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cash Price |
$454.50
|
| Rate for Payer: Cigna Commercial |
$671.71
|
| Rate for Payer: Healthspan PPO |
$547.25
|
| Rate for Payer: Humana Medicaid |
$319.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$130.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$362.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$362.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$325.94
|
| Rate for Payer: Molina Healthcare Passport |
$319.55
|
| Rate for Payer: Multiplan PHCS |
$545.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$470.76
|
| Rate for Payer: UHCCP Medicaid |
$318.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$322.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$362.12
|
|
|
RESPITE HOSPICE ROOM RATE
|
Facility
|
IP
|
$434.44
|
|
| Hospital Charge Code |
11000012
|
|
Hospital Revenue Code
|
110
|
| Min. Negotiated Rate |
$130.33 |
| Max. Negotiated Rate |
$417.06 |
| Rate for Payer: Aetna Commercial |
$334.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$338.86
|
| Rate for Payer: Cash Price |
$217.22
|
| Rate for Payer: Cigna Commercial |
$360.59
|
| Rate for Payer: First Health Commercial |
$412.72
|
| Rate for Payer: Humana Commercial |
$369.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$356.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$320.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$382.31
|
| Rate for Payer: Ohio Health Group HMO |
$325.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$377.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$299.76
|
| Rate for Payer: PHCS Commercial |
$417.06
|
| Rate for Payer: United Healthcare All Payer |
$382.31
|
|
|
RESPOSIT. GASTRIC FEEDING TUBE
|
Facility
|
OP
|
$1,646.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
76101792
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$1,580.16 |
| Rate for Payer: Aetna Commercial |
$1,267.42
|
| Rate for Payer: Anthem Medicaid |
$566.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,283.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$823.00
|
| Rate for Payer: Cash Price |
$823.00
|
| Rate for Payer: Cigna Commercial |
$1,366.18
|
| Rate for Payer: First Health Commercial |
$1,563.70
|
| Rate for Payer: Humana Commercial |
$1,399.10
|
| Rate for Payer: Humana KY Medicaid |
$566.06
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$571.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,349.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,214.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$577.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,448.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,234.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,316.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,432.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,135.74
|
| Rate for Payer: PHCS Commercial |
$1,580.16
|
| Rate for Payer: United Healthcare All Payer |
$1,448.48
|
|
