|
SANDOSTATINLAR 1MG 20MG DEPKIT
|
Facility
|
OP
|
$25,158.84
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.83 |
| Max. Negotiated Rate |
$24,152.49 |
| Rate for Payer: Aetna Commercial |
$19,372.31
|
| Rate for Payer: Anthem Medicaid |
$8,652.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$210.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,623.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$295.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$284.62
|
| Rate for Payer: Cash Price |
$12,579.42
|
| Rate for Payer: Cash Price |
$12,579.42
|
| Rate for Payer: Cigna Commercial |
$20,881.84
|
| Rate for Payer: First Health Commercial |
$23,900.90
|
| Rate for Payer: Humana Commercial |
$21,385.01
|
| Rate for Payer: Humana KY Medicaid |
$8,652.13
|
| Rate for Payer: Humana Medicare Advantage |
$210.83
|
| Rate for Payer: Kentucky WC Medicaid |
$8,740.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,630.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,567.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,825.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,139.78
|
| Rate for Payer: Ohio Health Group HMO |
$18,869.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,031.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,270.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,799.24
|
| Rate for Payer: PHCS Commercial |
$24,152.49
|
| Rate for Payer: United Healthcare All Payer |
$22,139.78
|
|
|
SANDOSTATINLAR 1MG 20MG DEPKIT
|
Facility
|
IP
|
$25,158.84
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002263
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,270.65 |
| Max. Negotiated Rate |
$24,152.49 |
| Rate for Payer: Aetna Commercial |
$19,372.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,623.90
|
| Rate for Payer: Cash Price |
$12,579.42
|
| Rate for Payer: Cigna Commercial |
$20,881.84
|
| Rate for Payer: First Health Commercial |
$23,900.90
|
| Rate for Payer: Humana Commercial |
$21,385.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,630.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,567.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,547.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,139.78
|
| Rate for Payer: Ohio Health Group HMO |
$18,869.13
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,031.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,270.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,799.24
|
| Rate for Payer: PHCS Commercial |
$24,152.49
|
| Rate for Payer: United Healthcare All Payer |
$22,139.78
|
|
|
SANDOSTATINLAR 1MG 30MG DEPKIT
|
Facility
|
OP
|
$37,673.45
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002264
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$210.83 |
| Max. Negotiated Rate |
$36,166.51 |
| Rate for Payer: Aetna Commercial |
$29,008.56
|
| Rate for Payer: Anthem Medicaid |
$12,955.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$210.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,385.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$295.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$284.62
|
| Rate for Payer: Cash Price |
$18,836.72
|
| Rate for Payer: Cash Price |
$18,836.72
|
| Rate for Payer: Cigna Commercial |
$31,268.96
|
| Rate for Payer: First Health Commercial |
$35,789.78
|
| Rate for Payer: Humana Commercial |
$32,022.43
|
| Rate for Payer: Humana KY Medicaid |
$12,955.90
|
| Rate for Payer: Humana Medicare Advantage |
$210.83
|
| Rate for Payer: Kentucky WC Medicaid |
$13,087.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,892.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,803.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$13,215.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,152.64
|
| Rate for Payer: Ohio Health Group HMO |
$28,255.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,534.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,897.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,678.77
|
| Rate for Payer: PHCS Commercial |
$36,166.51
|
| Rate for Payer: United Healthcare All Payer |
$33,152.64
|
|
|
SANDOSTATINLAR 1MG 30MG DEPKIT
|
Facility
|
IP
|
$37,673.45
|
|
|
Service Code
|
HCPCS J2353
|
| Hospital Charge Code |
25002264
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,897.55 |
| Max. Negotiated Rate |
$36,166.51 |
| Rate for Payer: Aetna Commercial |
$29,008.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$29,385.29
|
| Rate for Payer: Cash Price |
$18,836.72
|
| Rate for Payer: Cigna Commercial |
$31,268.96
|
| Rate for Payer: First Health Commercial |
$35,789.78
|
| Rate for Payer: Humana Commercial |
$32,022.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,892.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,803.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,302.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$33,152.64
|
| Rate for Payer: Ohio Health Group HMO |
$28,255.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,534.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,897.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,678.77
|
| Rate for Payer: PHCS Commercial |
$36,166.51
|
| Rate for Payer: United Healthcare All Payer |
$33,152.64
|
|
|
SANE EXAM
|
Facility
|
OP
|
$682.00
|
|
| Hospital Charge Code |
92900001
|
|
Hospital Revenue Code
|
929
|
| Min. Negotiated Rate |
$88.66 |
| Max. Negotiated Rate |
$654.72 |
| Rate for Payer: Aetna Commercial |
$525.14
|
| Rate for Payer: Anthem Medicaid |
$234.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$531.96
|
| Rate for Payer: Cash Price |
$341.00
|
| Rate for Payer: Cigna Commercial |
$566.06
|
| Rate for Payer: First Health Commercial |
$647.90
|
| Rate for Payer: Humana Commercial |
$579.70
|
| Rate for Payer: Humana KY Medicaid |
$234.54
|
| Rate for Payer: Kentucky WC Medicaid |
$236.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$559.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$503.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$204.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$239.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$600.16
|
| Rate for Payer: Ohio Health Group HMO |
$511.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$211.42
|
| Rate for Payer: PHCS Commercial |
$654.72
|
| Rate for Payer: United Healthcare All Payer |
$600.16
|
|
|
SANE EXAM
|
Facility
|
IP
|
$682.00
|
|
| Hospital Charge Code |
92900001
|
|
Hospital Revenue Code
|
929
|
| Min. Negotiated Rate |
$88.66 |
| Max. Negotiated Rate |
$654.72 |
| Rate for Payer: Aetna Commercial |
$525.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$531.96
|
| Rate for Payer: Cash Price |
$341.00
|
| Rate for Payer: Cigna Commercial |
$566.06
|
| Rate for Payer: First Health Commercial |
$647.90
|
| Rate for Payer: Humana Commercial |
$579.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$559.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$503.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$204.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$600.16
|
| Rate for Payer: Ohio Health Group HMO |
$511.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$211.42
|
| Rate for Payer: PHCS Commercial |
$654.72
|
| Rate for Payer: United Healthcare All Payer |
$600.16
|
|
|
SANTYL (COLLAGENASE) OINT 30GM
|
Facility
|
IP
|
$30.24
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
25001367
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$29.03 |
| Rate for Payer: Aetna Commercial |
$23.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.59
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna Commercial |
$25.10
|
| Rate for Payer: First Health Commercial |
$28.73
|
| Rate for Payer: Humana Commercial |
$25.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.61
|
| Rate for Payer: Ohio Health Group HMO |
$22.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.37
|
| Rate for Payer: PHCS Commercial |
$29.03
|
| Rate for Payer: United Healthcare All Payer |
$26.61
|
|
|
SANTYL (COLLAGENASE) OINT 30GM
|
Facility
|
OP
|
$30.24
|
|
|
Service Code
|
NDC 50484001030
|
| Hospital Charge Code |
25001367
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$29.03 |
| Rate for Payer: Aetna Commercial |
$23.28
|
| Rate for Payer: Anthem Medicaid |
$10.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.59
|
| Rate for Payer: Cash Price |
$15.12
|
| Rate for Payer: Cigna Commercial |
$25.10
|
| Rate for Payer: First Health Commercial |
$28.73
|
| Rate for Payer: Humana Commercial |
$25.70
|
| Rate for Payer: Humana KY Medicaid |
$10.40
|
| Rate for Payer: Kentucky WC Medicaid |
$10.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.61
|
| Rate for Payer: Ohio Health Group HMO |
$22.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.37
|
| Rate for Payer: PHCS Commercial |
$29.03
|
| Rate for Payer: United Healthcare All Payer |
$26.61
|
|
|
SAPHNELO 1MG (300mg SDV)
|
Facility
|
OP
|
$28,500.07
|
|
|
Service Code
|
HCPCS J0491
|
| Hospital Charge Code |
25004351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.18 |
| Max. Negotiated Rate |
$27,360.07 |
| Rate for Payer: Aetna Commercial |
$21,945.05
|
| Rate for Payer: Anthem Medicaid |
$9,801.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,230.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$23.19
|
| Rate for Payer: Cash Price |
$14,250.03
|
| Rate for Payer: Cash Price |
$14,250.03
|
| Rate for Payer: Cigna Commercial |
$23,655.06
|
| Rate for Payer: First Health Commercial |
$27,075.07
|
| Rate for Payer: Humana Commercial |
$24,225.06
|
| Rate for Payer: Humana KY Medicaid |
$9,801.17
|
| Rate for Payer: Humana Medicare Advantage |
$17.18
|
| Rate for Payer: Kentucky WC Medicaid |
$9,900.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,370.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,033.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,997.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,080.06
|
| Rate for Payer: Ohio Health Group HMO |
$21,375.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,700.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,705.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,835.02
|
| Rate for Payer: PHCS Commercial |
$27,360.07
|
| Rate for Payer: United Healthcare All Payer |
$25,080.06
|
|
|
SAPHNELO 1MG (300mg SDV)
|
Facility
|
IP
|
$28,500.07
|
|
|
Service Code
|
HCPCS J0491
|
| Hospital Charge Code |
25004351
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,705.01 |
| Max. Negotiated Rate |
$27,360.07 |
| Rate for Payer: Aetna Commercial |
$21,945.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,230.05
|
| Rate for Payer: Cash Price |
$14,250.03
|
| Rate for Payer: Cigna Commercial |
$23,655.06
|
| Rate for Payer: First Health Commercial |
$27,075.07
|
| Rate for Payer: Humana Commercial |
$24,225.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,370.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,033.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,550.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,080.06
|
| Rate for Payer: Ohio Health Group HMO |
$21,375.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,700.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,705.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,835.02
|
| Rate for Payer: PHCS Commercial |
$27,360.07
|
| Rate for Payer: United Healthcare All Payer |
$25,080.06
|
|
|
SAPPHIRE II PRO OTW 1.00*10
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*10
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*15
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*15
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*5
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*5
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*8
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO OTW 1.00*8
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*10
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*10
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*15
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*15
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*5
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*5
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
|
SAPPHIRE II PRO SZ 1.00*8
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.50 |
| Max. Negotiated Rate |
$1,968.00 |
| Rate for Payer: Aetna Commercial |
$1,578.50
|
| Rate for Payer: Anthem Medicaid |
$705.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Cash Price |
$1,025.00
|
| Rate for Payer: Cigna Commercial |
$1,701.50
|
| Rate for Payer: First Health Commercial |
$1,947.50
|
| Rate for Payer: Humana Commercial |
$1,742.50
|
| Rate for Payer: Humana KY Medicaid |
$705.00
|
| Rate for Payer: Kentucky WC Medicaid |
$712.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,681.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,512.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$615.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$719.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,804.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,537.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$410.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$266.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$635.50
|
| Rate for Payer: PHCS Commercial |
$1,968.00
|
| Rate for Payer: United Healthcare All Payer |
$1,804.00
|
|
