|
RYSTIGGO 1MG (280MG/2ML SDV)
|
Facility
|
OP
|
$32,972.50
|
|
|
Service Code
|
HCPCS J9333
|
| Hospital Charge Code |
25004488
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.26 |
| Max. Negotiated Rate |
$31,653.60 |
| Rate for Payer: Aetna Commercial |
$25,388.82
|
| Rate for Payer: Anthem Medicaid |
$11,339.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,718.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.04
|
| Rate for Payer: Cash Price |
$16,486.25
|
| Rate for Payer: Cash Price |
$16,486.25
|
| Rate for Payer: Cigna Commercial |
$27,367.18
|
| Rate for Payer: First Health Commercial |
$31,323.88
|
| Rate for Payer: Humana Commercial |
$28,026.62
|
| Rate for Payer: Humana KY Medicaid |
$11,339.24
|
| Rate for Payer: Humana Medicare Advantage |
$22.26
|
| Rate for Payer: Kentucky WC Medicaid |
$11,454.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,037.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,333.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,566.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$24,729.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,594.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,286.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,221.48
|
| Rate for Payer: PHCS Commercial |
$31,653.60
|
| Rate for Payer: United Healthcare All Payer |
$29,015.80
|
|
|
RYSTIGGO 1MG (280MG/2ML SDV)
|
Facility
|
IP
|
$32,972.50
|
|
|
Service Code
|
HCPCS J9333
|
| Hospital Charge Code |
25004488
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,286.42 |
| Max. Negotiated Rate |
$31,653.60 |
| Rate for Payer: Aetna Commercial |
$25,388.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,718.55
|
| Rate for Payer: Cash Price |
$16,486.25
|
| Rate for Payer: Cigna Commercial |
$27,367.18
|
| Rate for Payer: First Health Commercial |
$31,323.88
|
| Rate for Payer: Humana Commercial |
$28,026.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,037.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,333.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,891.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,015.80
|
| Rate for Payer: Ohio Health Group HMO |
$24,729.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,594.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,286.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,221.48
|
| Rate for Payer: PHCS Commercial |
$31,653.60
|
| Rate for Payer: United Healthcare All Payer |
$29,015.80
|
|
|
RYTHMOL (PROPAFENON 150MG/1TAB
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 591058201
|
| Hospital Charge Code |
25001352
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
RYTHMOL (PROPAFENON 150MG/1TAB
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 591058201
|
| Hospital Charge Code |
25001352
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
RYTHMOL(PROPAFENONE HCL)225MGT
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 62559023101
|
| Hospital Charge Code |
25001356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
RYTHMOL(PROPAFENONE HCL)225MGT
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 62559023101
|
| Hospital Charge Code |
25001356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.43
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
RYTHMOL SR 325 MG CAPSULE
|
Facility
|
IP
|
$10.78
|
|
|
Service Code
|
NDC 68462040960
|
| Hospital Charge Code |
25001354
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.41
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna Commercial |
$8.95
|
| Rate for Payer: First Health Commercial |
$10.24
|
| Rate for Payer: Humana Commercial |
$9.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.49
|
| Rate for Payer: Ohio Health Group HMO |
$8.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$10.35
|
| Rate for Payer: United Healthcare All Payer |
$9.49
|
|
|
RYTHMOL SR 325 MG CAPSULE
|
Facility
|
OP
|
$10.78
|
|
|
Service Code
|
NDC 68462040960
|
| Hospital Charge Code |
25001354
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$10.35 |
| Rate for Payer: Aetna Commercial |
$8.30
|
| Rate for Payer: Anthem Medicaid |
$3.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.41
|
| Rate for Payer: Cash Price |
$5.39
|
| Rate for Payer: Cigna Commercial |
$8.95
|
| Rate for Payer: First Health Commercial |
$10.24
|
| Rate for Payer: Humana Commercial |
$9.16
|
| Rate for Payer: Humana KY Medicaid |
$3.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.49
|
| Rate for Payer: Ohio Health Group HMO |
$8.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.34
|
| Rate for Payer: PHCS Commercial |
$10.35
|
| Rate for Payer: United Healthcare All Payer |
$9.49
|
|
|
RYTHMOL SR (PROPAFENO) 225MG T
|
Facility
|
OP
|
$10.19
|
|
|
Service Code
|
NDC 68462040860
|
| Hospital Charge Code |
25001353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.95
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.46
|
| Rate for Payer: First Health Commercial |
$9.68
|
| Rate for Payer: Humana Commercial |
$8.66
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.97
|
| Rate for Payer: Ohio Health Group HMO |
$7.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Payer |
$8.97
|
|
|
RYTHMOL SR (PROPAFENO) 225MG T
|
Facility
|
IP
|
$10.19
|
|
|
Service Code
|
NDC 68462040860
|
| Hospital Charge Code |
25001353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.95
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.46
|
| Rate for Payer: First Health Commercial |
$9.68
|
| Rate for Payer: Humana Commercial |
$8.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.97
|
| Rate for Payer: Ohio Health Group HMO |
$7.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Payer |
$8.97
|
|
|
SABER BALLOON 10*10*90
|
Facility
|
IP
|
$2,102.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$273.32 |
| Max. Negotiated Rate |
$2,018.40 |
| Rate for Payer: Aetna Commercial |
$1,618.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,639.95
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cigna Commercial |
$1,745.08
|
| Rate for Payer: First Health Commercial |
$1,997.38
|
| Rate for Payer: Humana Commercial |
$1,787.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,724.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,551.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,850.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,576.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$651.78
|
| Rate for Payer: PHCS Commercial |
$2,018.40
|
| Rate for Payer: United Healthcare All Payer |
$1,850.20
|
|
|
SABER BALLOON 10*10*90
|
Facility
|
OP
|
$2,102.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$273.32 |
| Max. Negotiated Rate |
$2,018.40 |
| Rate for Payer: Aetna Commercial |
$1,618.92
|
| Rate for Payer: Anthem Medicaid |
$723.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,639.95
|
| Rate for Payer: Cash Price |
$1,051.25
|
| Rate for Payer: Cigna Commercial |
$1,745.08
|
| Rate for Payer: First Health Commercial |
$1,997.38
|
| Rate for Payer: Humana Commercial |
$1,787.12
|
| Rate for Payer: Humana KY Medicaid |
$723.05
|
| Rate for Payer: Kentucky WC Medicaid |
$730.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,724.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,551.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$630.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$737.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,850.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,576.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$420.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$651.78
|
| Rate for Payer: PHCS Commercial |
$2,018.40
|
| Rate for Payer: United Healthcare All Payer |
$1,850.20
|
|
|
SABER BALLOON 10*6*90
|
Facility
|
IP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$1,833.60 |
| Rate for Payer: Aetna Commercial |
$1,470.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.80
|
| Rate for Payer: Cash Price |
$955.00
|
| Rate for Payer: Cigna Commercial |
$1,585.30
|
| Rate for Payer: First Health Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial |
$1,623.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,566.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.10
|
| Rate for Payer: PHCS Commercial |
$1,833.60
|
| Rate for Payer: United Healthcare All Payer |
$1,680.80
|
|
|
SABER BALLOON 10*6*90
|
Facility
|
OP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$1,833.60 |
| Rate for Payer: Aetna Commercial |
$1,470.70
|
| Rate for Payer: Anthem Medicaid |
$656.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.80
|
| Rate for Payer: Cash Price |
$955.00
|
| Rate for Payer: Cigna Commercial |
$1,585.30
|
| Rate for Payer: First Health Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial |
$1,623.50
|
| Rate for Payer: Humana KY Medicaid |
$656.85
|
| Rate for Payer: Kentucky WC Medicaid |
$663.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,566.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$670.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.10
|
| Rate for Payer: PHCS Commercial |
$1,833.60
|
| Rate for Payer: United Healthcare All Payer |
$1,680.80
|
|
|
SABER BALLOON 10*8*90
|
Facility
|
IP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$1,833.60 |
| Rate for Payer: Aetna Commercial |
$1,470.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.80
|
| Rate for Payer: Cash Price |
$955.00
|
| Rate for Payer: Cigna Commercial |
$1,585.30
|
| Rate for Payer: First Health Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial |
$1,623.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,566.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.10
|
| Rate for Payer: PHCS Commercial |
$1,833.60
|
| Rate for Payer: United Healthcare All Payer |
$1,680.80
|
|
|
SABER BALLOON 10*8*90
|
Facility
|
OP
|
$1,910.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$248.30 |
| Max. Negotiated Rate |
$1,833.60 |
| Rate for Payer: Aetna Commercial |
$1,470.70
|
| Rate for Payer: Anthem Medicaid |
$656.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,489.80
|
| Rate for Payer: Cash Price |
$955.00
|
| Rate for Payer: Cigna Commercial |
$1,585.30
|
| Rate for Payer: First Health Commercial |
$1,814.50
|
| Rate for Payer: Humana Commercial |
$1,623.50
|
| Rate for Payer: Humana KY Medicaid |
$656.85
|
| Rate for Payer: Kentucky WC Medicaid |
$663.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,566.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,409.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$573.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$670.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,680.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,432.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$382.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$248.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.10
|
| Rate for Payer: PHCS Commercial |
$1,833.60
|
| Rate for Payer: United Healthcare All Payer |
$1,680.80
|
|
|
SABER BALLOON 2*25*150
|
Facility
|
OP
|
$2,137.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.88 |
| Max. Negotiated Rate |
$2,052.00 |
| Rate for Payer: Aetna Commercial |
$1,645.88
|
| Rate for Payer: Anthem Medicaid |
$735.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.25
|
| Rate for Payer: Cash Price |
$1,068.75
|
| Rate for Payer: Cigna Commercial |
$1,774.12
|
| Rate for Payer: First Health Commercial |
$2,030.62
|
| Rate for Payer: Humana Commercial |
$1,816.88
|
| Rate for Payer: Humana KY Medicaid |
$735.09
|
| Rate for Payer: Kentucky WC Medicaid |
$742.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,752.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$749.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.62
|
| Rate for Payer: PHCS Commercial |
$2,052.00
|
| Rate for Payer: United Healthcare All Payer |
$1,881.00
|
|
|
SABER BALLOON 2*25*150
|
Facility
|
IP
|
$2,137.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.88 |
| Max. Negotiated Rate |
$2,052.00 |
| Rate for Payer: Aetna Commercial |
$1,645.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.25
|
| Rate for Payer: Cash Price |
$1,068.75
|
| Rate for Payer: Cigna Commercial |
$1,774.12
|
| Rate for Payer: First Health Commercial |
$2,030.62
|
| Rate for Payer: Humana Commercial |
$1,816.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,752.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.62
|
| Rate for Payer: PHCS Commercial |
$2,052.00
|
| Rate for Payer: United Healthcare All Payer |
$1,881.00
|
|
|
SABER BALLOON 2*25*90
|
Facility
|
OP
|
$2,137.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.88 |
| Max. Negotiated Rate |
$2,052.00 |
| Rate for Payer: Aetna Commercial |
$1,645.88
|
| Rate for Payer: Anthem Medicaid |
$735.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.25
|
| Rate for Payer: Cash Price |
$1,068.75
|
| Rate for Payer: Cigna Commercial |
$1,774.12
|
| Rate for Payer: First Health Commercial |
$2,030.62
|
| Rate for Payer: Humana Commercial |
$1,816.88
|
| Rate for Payer: Humana KY Medicaid |
$735.09
|
| Rate for Payer: Kentucky WC Medicaid |
$742.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,752.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$749.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.62
|
| Rate for Payer: PHCS Commercial |
$2,052.00
|
| Rate for Payer: United Healthcare All Payer |
$1,881.00
|
|
|
SABER BALLOON 2*25*90
|
Facility
|
IP
|
$2,137.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.88 |
| Max. Negotiated Rate |
$2,052.00 |
| Rate for Payer: Aetna Commercial |
$1,645.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.25
|
| Rate for Payer: Cash Price |
$1,068.75
|
| Rate for Payer: Cigna Commercial |
$1,774.12
|
| Rate for Payer: First Health Commercial |
$2,030.62
|
| Rate for Payer: Humana Commercial |
$1,816.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,752.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.62
|
| Rate for Payer: PHCS Commercial |
$2,052.00
|
| Rate for Payer: United Healthcare All Payer |
$1,881.00
|
|
|
SABER BALLOON 2*30*150
|
Facility
|
OP
|
$2,176.88
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$282.99 |
| Max. Negotiated Rate |
$2,089.80 |
| Rate for Payer: Aetna Commercial |
$1,676.20
|
| Rate for Payer: Anthem Medicaid |
$748.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,697.97
|
| Rate for Payer: Cash Price |
$1,088.44
|
| Rate for Payer: Cigna Commercial |
$1,806.81
|
| Rate for Payer: First Health Commercial |
$2,068.04
|
| Rate for Payer: Humana Commercial |
$1,850.35
|
| Rate for Payer: Humana KY Medicaid |
$748.63
|
| Rate for Payer: Kentucky WC Medicaid |
$756.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,785.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,606.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$653.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$763.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,915.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,632.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$674.83
|
| Rate for Payer: PHCS Commercial |
$2,089.80
|
| Rate for Payer: United Healthcare All Payer |
$1,915.65
|
|
|
SABER BALLOON 2*30*150
|
Facility
|
IP
|
$2,176.88
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$282.99 |
| Max. Negotiated Rate |
$2,089.80 |
| Rate for Payer: Aetna Commercial |
$1,676.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,697.97
|
| Rate for Payer: Cash Price |
$1,088.44
|
| Rate for Payer: Cigna Commercial |
$1,806.81
|
| Rate for Payer: First Health Commercial |
$2,068.04
|
| Rate for Payer: Humana Commercial |
$1,850.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,785.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,606.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$653.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,915.65
|
| Rate for Payer: Ohio Health Group HMO |
$1,632.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$282.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$674.83
|
| Rate for Payer: PHCS Commercial |
$2,089.80
|
| Rate for Payer: United Healthcare All Payer |
$1,915.65
|
|
|
SABER BALLOON 3*20*150
|
Facility
|
IP
|
$2,137.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.88 |
| Max. Negotiated Rate |
$2,052.00 |
| Rate for Payer: Aetna Commercial |
$1,645.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.25
|
| Rate for Payer: Cash Price |
$1,068.75
|
| Rate for Payer: Cigna Commercial |
$1,774.12
|
| Rate for Payer: First Health Commercial |
$2,030.62
|
| Rate for Payer: Humana Commercial |
$1,816.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,752.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.62
|
| Rate for Payer: PHCS Commercial |
$2,052.00
|
| Rate for Payer: United Healthcare All Payer |
$1,881.00
|
|
|
SABER BALLOON 3*20*150
|
Facility
|
OP
|
$2,137.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$277.88 |
| Max. Negotiated Rate |
$2,052.00 |
| Rate for Payer: Aetna Commercial |
$1,645.88
|
| Rate for Payer: Anthem Medicaid |
$735.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,667.25
|
| Rate for Payer: Cash Price |
$1,068.75
|
| Rate for Payer: Cigna Commercial |
$1,774.12
|
| Rate for Payer: First Health Commercial |
$2,030.62
|
| Rate for Payer: Humana Commercial |
$1,816.88
|
| Rate for Payer: Humana KY Medicaid |
$735.09
|
| Rate for Payer: Kentucky WC Medicaid |
$742.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,752.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,577.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$749.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,881.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,603.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$427.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$277.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$662.62
|
| Rate for Payer: PHCS Commercial |
$2,052.00
|
| Rate for Payer: United Healthcare All Payer |
$1,881.00
|
|
|
SABER BALLOON 3*25*150
|
Facility
|
OP
|
$2,218.21
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$288.37 |
| Max. Negotiated Rate |
$2,129.48 |
| Rate for Payer: Aetna Commercial |
$1,708.02
|
| Rate for Payer: Anthem Medicaid |
$762.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,730.20
|
| Rate for Payer: Cash Price |
$1,109.11
|
| Rate for Payer: Cigna Commercial |
$1,841.11
|
| Rate for Payer: First Health Commercial |
$2,107.30
|
| Rate for Payer: Humana Commercial |
$1,885.48
|
| Rate for Payer: Humana KY Medicaid |
$762.84
|
| Rate for Payer: Kentucky WC Medicaid |
$770.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,818.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,637.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$665.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$778.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,952.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,663.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$443.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$288.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$687.65
|
| Rate for Payer: PHCS Commercial |
$2,129.48
|
| Rate for Payer: United Healthcare All Payer |
$1,952.02
|
|
