|
RESURF W/JRNY ELIP PAT PEG 38
|
Facility
|
OP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem Medicaid |
$1,139.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Humana KY Medicaid |
$1,139.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,150.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,162.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 41
|
Facility
|
OP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem Medicaid |
$1,139.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Humana KY Medicaid |
$1,139.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,150.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,162.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 41
|
Facility
|
IP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESUR PAT GEN 11 7.5MM 26MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 26MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 29MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 29MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 32MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 32MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 35MM
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RESUR PAT GEN 11 7.5MM 35MM
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
RETACRIT 10000 UNIT/ML VIAL
|
Facility
|
OP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem Medicaid |
$206.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.22
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Humana KY Medicaid |
$206.73
|
| Rate for Payer: Humana Medicare Advantage |
$7.57
|
| Rate for Payer: Kentucky WC Medicaid |
$208.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.79
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 10000 UNIT/ML VIAL
|
Facility
|
IP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002728
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$180.34 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.79
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 1,000u (20,000u MDV)
|
Facility
|
IP
|
$60.11
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25004158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.89
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cigna Commercial |
$49.89
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.90
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.48
|
| Rate for Payer: PHCS Commercial |
$57.71
|
| Rate for Payer: United Healthcare All Payer |
$52.90
|
|
|
RETACRIT 1,000u (20,000u MDV)
|
Facility
|
OP
|
$60.11
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25004158
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$57.71 |
| Rate for Payer: Aetna Commercial |
$46.28
|
| Rate for Payer: Anthem Medicaid |
$20.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.22
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cash Price |
$30.06
|
| Rate for Payer: Cigna Commercial |
$49.89
|
| Rate for Payer: First Health Commercial |
$57.10
|
| Rate for Payer: Humana Commercial |
$51.09
|
| Rate for Payer: Humana KY Medicaid |
$20.67
|
| Rate for Payer: Humana Medicare Advantage |
$7.57
|
| Rate for Payer: Kentucky WC Medicaid |
$20.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.90
|
| Rate for Payer: Ohio Health Group HMO |
$45.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.48
|
| Rate for Payer: PHCS Commercial |
$57.71
|
| Rate for Payer: United Healthcare All Payer |
$52.90
|
|
|
RETACRIT 100U (10KSDV)(ONHD)
|
Facility
|
IP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004495
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$180.34 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.79
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 100U (10KSDV)(ONHD)
|
Facility
|
OP
|
$601.14
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004495
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$577.09 |
| Rate for Payer: Aetna Commercial |
$462.88
|
| Rate for Payer: Anthem Medicaid |
$206.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cash Price |
$300.57
|
| Rate for Payer: Cigna Commercial |
$498.95
|
| Rate for Payer: First Health Commercial |
$571.08
|
| Rate for Payer: Humana Commercial |
$510.97
|
| Rate for Payer: Humana KY Medicaid |
$206.73
|
| Rate for Payer: Humana Medicare Advantage |
$0.76
|
| Rate for Payer: Kentucky WC Medicaid |
$208.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$443.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$529.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.79
|
| Rate for Payer: PHCS Commercial |
$577.09
|
| Rate for Payer: United Healthcare All Payer |
$529.00
|
|
|
RETACRIT 100U (20KMDV)(ONHD)
|
Facility
|
OP
|
$1,202.27
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004496
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$1,154.18 |
| Rate for Payer: Aetna Commercial |
$925.75
|
| Rate for Payer: Anthem Medicaid |
$413.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$937.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$601.14
|
| Rate for Payer: Cash Price |
$601.14
|
| Rate for Payer: Cigna Commercial |
$997.88
|
| Rate for Payer: First Health Commercial |
$1,142.16
|
| Rate for Payer: Humana Commercial |
$1,021.93
|
| Rate for Payer: Humana KY Medicaid |
$413.46
|
| Rate for Payer: Humana Medicare Advantage |
$0.76
|
| Rate for Payer: Kentucky WC Medicaid |
$417.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$985.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$887.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$421.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,058.00
|
| Rate for Payer: Ohio Health Group HMO |
$901.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$961.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,045.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$829.57
|
| Rate for Payer: PHCS Commercial |
$1,154.18
|
| Rate for Payer: United Healthcare All Payer |
$1,058.00
|
|
|
RETACRIT 100U (20KMDV)(ONHD)
|
Facility
|
IP
|
$1,202.27
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004496
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$360.68 |
| Max. Negotiated Rate |
$1,154.18 |
| Rate for Payer: Aetna Commercial |
$925.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$937.77
|
| Rate for Payer: Cash Price |
$601.14
|
| Rate for Payer: Cigna Commercial |
$997.88
|
| Rate for Payer: First Health Commercial |
$1,142.16
|
| Rate for Payer: Humana Commercial |
$1,021.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$985.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$887.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,058.00
|
| Rate for Payer: Ohio Health Group HMO |
$901.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$961.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,045.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$829.57
|
| Rate for Payer: PHCS Commercial |
$1,154.18
|
| Rate for Payer: United Healthcare All Payer |
$1,058.00
|
|
|
RETACRIT 100U (2K SDV)(ONHD)
|
Facility
|
OP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004497
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem Medicaid |
$41.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Humana KY Medicaid |
$41.35
|
| Rate for Payer: Humana Medicare Advantage |
$0.76
|
| Rate for Payer: Kentucky WC Medicaid |
$41.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.96
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 100U (2K SDV)(ONHD)
|
Facility
|
IP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004497
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$36.07 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.96
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 100U(3KSDV)(ONHD)
|
Facility
|
IP
|
$180.34
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004498
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$54.10 |
| Max. Negotiated Rate |
$173.13 |
| Rate for Payer: Aetna Commercial |
$138.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.67
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cigna Commercial |
$149.68
|
| Rate for Payer: First Health Commercial |
$171.32
|
| Rate for Payer: Humana Commercial |
$153.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$54.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.70
|
| Rate for Payer: Ohio Health Group HMO |
$135.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.43
|
| Rate for Payer: PHCS Commercial |
$173.13
|
| Rate for Payer: United Healthcare All Payer |
$158.70
|
|
|
RETACRIT 100U(3KSDV)(ONHD)
|
Facility
|
OP
|
$180.34
|
|
|
Service Code
|
HCPCS Q5105
|
| Hospital Charge Code |
25004498
|
|
Hospital Revenue Code
|
635
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$173.13 |
| Rate for Payer: Aetna Commercial |
$138.86
|
| Rate for Payer: Anthem Medicaid |
$62.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$140.67
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.06
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cash Price |
$90.17
|
| Rate for Payer: Cigna Commercial |
$149.68
|
| Rate for Payer: First Health Commercial |
$171.32
|
| Rate for Payer: Humana Commercial |
$153.29
|
| Rate for Payer: Humana KY Medicaid |
$62.02
|
| Rate for Payer: Humana Medicare Advantage |
$0.76
|
| Rate for Payer: Kentucky WC Medicaid |
$62.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$147.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$133.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$63.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$158.70
|
| Rate for Payer: Ohio Health Group HMO |
$135.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$144.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$156.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$124.43
|
| Rate for Payer: PHCS Commercial |
$173.13
|
| Rate for Payer: United Healthcare All Payer |
$158.70
|
|
|
RETACRIT 2000 UNIT/ML VL
|
Facility
|
OP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.57 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem Medicaid |
$41.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.22
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Humana KY Medicaid |
$41.35
|
| Rate for Payer: Humana Medicare Advantage |
$7.57
|
| Rate for Payer: Kentucky WC Medicaid |
$41.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.96
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
|
RETACRIT 2000 UNIT/ML VL
|
Facility
|
IP
|
$120.23
|
|
|
Service Code
|
HCPCS Q5106
|
| Hospital Charge Code |
25002729
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.07 |
| Max. Negotiated Rate |
$115.42 |
| Rate for Payer: Aetna Commercial |
$92.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.78
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.79
|
| Rate for Payer: First Health Commercial |
$114.22
|
| Rate for Payer: Humana Commercial |
$102.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.80
|
| Rate for Payer: Ohio Health Group HMO |
$90.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.96
|
| Rate for Payer: PHCS Commercial |
$115.42
|
| Rate for Payer: United Healthcare All Payer |
$105.80
|
|
