|
REV POR 170MM STR SZ 15
|
Facility
|
OP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem Medicaid |
$5,366.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Humana KY Medicaid |
$5,366.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5,421.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,474.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 15
|
Facility
|
IP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 16
|
Facility
|
IP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 16
|
Facility
|
OP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem Medicaid |
$5,366.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Humana KY Medicaid |
$5,366.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5,421.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,474.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 17
|
Facility
|
IP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 17
|
Facility
|
OP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem Medicaid |
$5,366.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Humana KY Medicaid |
$5,366.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5,421.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,474.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 18
|
Facility
|
OP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem Medicaid |
$5,366.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Humana KY Medicaid |
$5,366.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5,421.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,474.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 18
|
Facility
|
IP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 19
|
Facility
|
OP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem Medicaid |
$5,366.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Humana KY Medicaid |
$5,366.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5,421.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,474.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 19
|
Facility
|
IP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 20
|
Facility
|
OP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem Medicaid |
$5,366.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Humana KY Medicaid |
$5,366.78
|
| Rate for Payer: Kentucky WC Medicaid |
$5,421.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,474.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REV POR 170MM STR SZ 20
|
Facility
|
IP
|
$15,605.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,681.69 |
| Max. Negotiated Rate |
$14,981.41 |
| Rate for Payer: Aetna Commercial |
$12,016.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,172.40
|
| Rate for Payer: Cash Price |
$7,802.82
|
| Rate for Payer: Cigna Commercial |
$12,952.68
|
| Rate for Payer: First Health Commercial |
$14,825.36
|
| Rate for Payer: Humana Commercial |
$13,264.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,796.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,516.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,681.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,732.96
|
| Rate for Payer: Ohio Health Group HMO |
$11,704.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,484.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,576.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,767.89
|
| Rate for Payer: PHCS Commercial |
$14,981.41
|
| Rate for Payer: United Healthcare All Payer |
$13,732.96
|
|
|
REVSC OPN/PRQ TIB/PERO STEN(P
|
Professional
|
Both
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
761P1558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.13 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$475.04
|
| Rate for Payer: Ambetter Exchange |
$262.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$143.13
|
| Rate for Payer: Anthem Medicaid |
$3,387.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$262.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$262.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$314.81
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$538.20
|
| Rate for Payer: Healthspan PPO |
$3,613.90
|
| Rate for Payer: Humana Medicaid |
$3,387.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$262.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,455.17
|
| Rate for Payer: Molina Healthcare Passport |
$3,387.42
|
| Rate for Payer: Multiplan PHCS |
$4,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$341.04
|
| Rate for Payer: UHCCP Medicaid |
$150.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,421.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$262.34
|
|
|
REVSC OPN/PRQ TIB/PERO STENT
|
Facility
|
OP
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
76101558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,400.00 |
| Max. Negotiated Rate |
$7,680.00 |
| Rate for Payer: Aetna Commercial |
$6,160.00
|
| Rate for Payer: Anthem Medicaid |
$2,751.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$6,640.00
|
| Rate for Payer: First Health Commercial |
$7,600.00
|
| Rate for Payer: Humana Commercial |
$6,800.00
|
| Rate for Payer: Humana KY Medicaid |
$2,751.20
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,560.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,960.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,520.00
|
| Rate for Payer: PHCS Commercial |
$7,680.00
|
| Rate for Payer: United Healthcare All Payer |
$7,040.00
|
|
|
REVSC OPN/PRQ TIB/PERO STENT
|
Professional
|
Both
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
76101558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.13 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$475.04
|
| Rate for Payer: Ambetter Exchange |
$262.34
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$143.13
|
| Rate for Payer: Anthem Medicaid |
$3,387.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$262.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$262.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$314.81
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$538.20
|
| Rate for Payer: Healthspan PPO |
$3,613.90
|
| Rate for Payer: Humana Medicaid |
$3,387.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$370.32
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$262.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$262.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$3,455.17
|
| Rate for Payer: Molina Healthcare Passport |
$3,387.42
|
| Rate for Payer: Multiplan PHCS |
$4,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$341.04
|
| Rate for Payer: UHCCP Medicaid |
$150.29
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3,421.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$262.34
|
|
|
REVSC OPN/PRQ TIB/PERO STENT
|
Facility
|
IP
|
$8,000.00
|
|
|
Service Code
|
HCPCS 37234
|
| Hospital Charge Code |
76101558
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,400.00 |
| Max. Negotiated Rate |
$7,680.00 |
| Rate for Payer: Aetna Commercial |
$6,160.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.00
|
| Rate for Payer: Cash Price |
$4,000.00
|
| Rate for Payer: Cigna Commercial |
$6,640.00
|
| Rate for Payer: First Health Commercial |
$7,600.00
|
| Rate for Payer: Humana Commercial |
$6,800.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,560.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,040.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,960.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,520.00
|
| Rate for Payer: PHCS Commercial |
$7,680.00
|
| Rate for Payer: United Healthcare All Payer |
$7,040.00
|
|
|
Revuna 1.5 cc
|
Professional
|
Both
|
$1,040.00
|
|
| Hospital Charge Code |
22200704
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$728.00 |
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$728.00
|
| Rate for Payer: UHCCP Medicaid |
$364.00
|
|
|
Revuna 3.0 cc
|
Professional
|
Both
|
$2,060.00
|
|
| Hospital Charge Code |
22200705
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$721.00 |
| Max. Negotiated Rate |
$1,442.00 |
| Rate for Payer: Cash Price |
$1,030.00
|
| Rate for Payer: Multiplan PHCS |
$1,236.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,442.00
|
| Rate for Payer: UHCCP Medicaid |
$721.00
|
|
|
REXULTI 0.25MG TABLET
|
Facility
|
OP
|
$122.52
|
|
|
Service Code
|
NDC 59148003513
|
| Hospital Charge Code |
25003411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem Medicaid |
$42.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Humana KY Medicaid |
$42.13
|
| Rate for Payer: Kentucky WC Medicaid |
$42.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
|
REXULTI 0.25MG TABLET
|
Facility
|
IP
|
$122.52
|
|
|
Service Code
|
NDC 59148003513
|
| Hospital Charge Code |
25003411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
|
REXULTI 0.5MG TABLET
|
Facility
|
OP
|
$122.52
|
|
|
Service Code
|
NDC 59148003613
|
| Hospital Charge Code |
25003412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem Medicaid |
$42.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Humana KY Medicaid |
$42.13
|
| Rate for Payer: Kentucky WC Medicaid |
$42.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
|
REXULTI 0.5MG TABLET
|
Facility
|
IP
|
$122.52
|
|
|
Service Code
|
NDC 59148003613
|
| Hospital Charge Code |
25003412
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
|
REXULTI 1MG TABLET
|
Facility
|
OP
|
$122.52
|
|
|
Service Code
|
NDC 59148003713
|
| Hospital Charge Code |
25003413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem Medicaid |
$42.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Humana KY Medicaid |
$42.13
|
| Rate for Payer: Kentucky WC Medicaid |
$42.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
|
REXULTI 1MG TABLET
|
Facility
|
IP
|
$122.52
|
|
|
Service Code
|
NDC 59148003713
|
| Hospital Charge Code |
25003413
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
|
REXULTI 2MG TABLET
|
Facility
|
IP
|
$122.52
|
|
|
Service Code
|
NDC 59148003813
|
| Hospital Charge Code |
25003414
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.76 |
| Max. Negotiated Rate |
$117.62 |
| Rate for Payer: Aetna Commercial |
$94.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$95.57
|
| Rate for Payer: Cash Price |
$61.26
|
| Rate for Payer: Cigna Commercial |
$101.69
|
| Rate for Payer: First Health Commercial |
$116.39
|
| Rate for Payer: Humana Commercial |
$104.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$107.82
|
| Rate for Payer: Ohio Health Group HMO |
$91.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.54
|
| Rate for Payer: PHCS Commercial |
$117.62
|
| Rate for Payer: United Healthcare All Payer |
$107.82
|
|
