|
REXULTI 2MG TABLET
|
Facility
|
OP
|
$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 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 3MG TABLET
|
Facility
|
IP
|
$122.52
|
|
|
Service Code
|
NDC 59148003913
|
| Hospital Charge Code |
25003415
|
|
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 3MG TABLET
|
Facility
|
OP
|
$122.52
|
|
|
Service Code
|
NDC 59148003913
|
| Hospital Charge Code |
25003415
|
|
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 4MG TABLET
|
Facility
|
IP
|
$122.52
|
|
|
Service Code
|
NDC 59148004013
|
| Hospital Charge Code |
25003416
|
|
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 4MG TABLET
|
Facility
|
OP
|
$122.52
|
|
|
Service Code
|
NDC 59148004013
|
| Hospital Charge Code |
25003416
|
|
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
|
|
|
RF ABLATION NRV SI JOINT
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
76102921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,750.45 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
RF ABLATION NRV SI JOINT
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
76102921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
RF ABLATION NRV SI JOINT
|
Professional
|
Both
|
$5,090.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
76102921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.42 |
| Max. Negotiated Rate |
$3,054.00 |
| Rate for Payer: Ambetter Exchange |
$184.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$156.42
|
| Rate for Payer: Anthem Medicaid |
$377.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$184.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$184.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$221.90
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Humana Medicaid |
$377.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$250.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$184.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$184.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.00
|
| Rate for Payer: Molina Healthcare Passport |
$377.45
|
| Rate for Payer: Multiplan PHCS |
$3,054.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$240.40
|
| Rate for Payer: UHCCP Medicaid |
$164.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$184.92
|
|
|
RF ABLATION NRV SI JOINT (P
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
761P2921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$156.42 |
| Max. Negotiated Rate |
$385.00 |
| Rate for Payer: Ambetter Exchange |
$184.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$156.42
|
| Rate for Payer: Anthem Medicaid |
$377.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$184.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$184.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$221.90
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Humana Medicaid |
$377.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$250.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$184.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$184.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$385.00
|
| Rate for Payer: Molina Healthcare Passport |
$377.45
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$240.40
|
| Rate for Payer: UHCCP Medicaid |
$164.24
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.22
|
| Rate for Payer: Wellcare Medicare Advantage |
$184.92
|
|
|
RF ABLATION NRV SI JOINT (T
|
Facility
|
IP
|
$4,615.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
761T2921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,384.50 |
| Max. Negotiated Rate |
$4,430.40 |
| Rate for Payer: Aetna Commercial |
$3,553.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,599.70
|
| Rate for Payer: Cash Price |
$2,307.50
|
| Rate for Payer: Cigna Commercial |
$3,830.45
|
| Rate for Payer: First Health Commercial |
$4,384.25
|
| Rate for Payer: Humana Commercial |
$3,922.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,784.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,405.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,384.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,061.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,461.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,692.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,015.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,184.35
|
| Rate for Payer: PHCS Commercial |
$4,430.40
|
| Rate for Payer: United Healthcare All Payer |
$4,061.20
|
|
|
RF ABLATION NRV SI JOINT (T
|
Facility
|
OP
|
$4,615.00
|
|
|
Service Code
|
HCPCS 64625
|
| Hospital Charge Code |
761T2921
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,587.10 |
| Max. Negotiated Rate |
$4,430.40 |
| Rate for Payer: Aetna Commercial |
$3,553.55
|
| Rate for Payer: Anthem Medicaid |
$1,587.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,804.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,599.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,526.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,435.83
|
| Rate for Payer: Cash Price |
$2,307.50
|
| Rate for Payer: Cash Price |
$2,307.50
|
| Rate for Payer: Cigna Commercial |
$3,830.45
|
| Rate for Payer: First Health Commercial |
$4,384.25
|
| Rate for Payer: Humana Commercial |
$3,922.75
|
| Rate for Payer: Humana KY Medicaid |
$1,587.10
|
| Rate for Payer: Humana Medicare Advantage |
$1,804.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,603.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,784.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,405.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,165.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,618.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,061.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,461.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,692.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,015.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,184.35
|
| Rate for Payer: PHCS Commercial |
$4,430.40
|
| Rate for Payer: United Healthcare All Payer |
$4,061.20
|
|
|
RF ACET MH SZ 50E
|
Facility
|
IP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 50E
|
Facility
|
OP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem Medicaid |
$4,542.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Humana KY Medicaid |
$4,542.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,588.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,633.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 52E
|
Facility
|
OP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem Medicaid |
$4,542.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Humana KY Medicaid |
$4,542.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,588.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,633.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 52E
|
Facility
|
IP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 54F
|
Facility
|
IP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 54F
|
Facility
|
OP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem Medicaid |
$4,542.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Humana KY Medicaid |
$4,542.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,588.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,633.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 56F
|
Facility
|
IP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 56F
|
Facility
|
OP
|
$13,208.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,962.70 |
| Max. Negotiated Rate |
$12,680.63 |
| Rate for Payer: Aetna Commercial |
$10,170.92
|
| Rate for Payer: Anthem Medicaid |
$4,542.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,303.01
|
| Rate for Payer: Cash Price |
$6,604.49
|
| Rate for Payer: Cigna Commercial |
$10,963.46
|
| Rate for Payer: First Health Commercial |
$12,548.54
|
| Rate for Payer: Humana Commercial |
$11,227.64
|
| Rate for Payer: Humana KY Medicaid |
$4,542.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,588.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,831.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,748.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,962.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,633.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,623.91
|
| Rate for Payer: Ohio Health Group HMO |
$9,906.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,567.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,491.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,114.20
|
| Rate for Payer: PHCS Commercial |
$12,680.63
|
| Rate for Payer: United Healthcare All Payer |
$11,623.91
|
|
|
RF ACET MH SZ 58G
|
Facility
|
IP
|
$14,330.17
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,299.05 |
| Max. Negotiated Rate |
$13,756.96 |
| Rate for Payer: Aetna Commercial |
$11,034.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,177.53
|
| Rate for Payer: Cash Price |
$7,165.08
|
| Rate for Payer: Cigna Commercial |
$11,894.04
|
| Rate for Payer: First Health Commercial |
$13,613.66
|
| Rate for Payer: Humana Commercial |
$12,180.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,750.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,575.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,299.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,610.55
|
| Rate for Payer: Ohio Health Group HMO |
$10,747.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,464.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,467.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,887.82
|
| Rate for Payer: PHCS Commercial |
$13,756.96
|
| Rate for Payer: United Healthcare All Payer |
$12,610.55
|
|
|
RF ACET MH SZ 58G
|
Facility
|
OP
|
$14,330.17
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,299.05 |
| Max. Negotiated Rate |
$13,756.96 |
| Rate for Payer: Aetna Commercial |
$11,034.23
|
| Rate for Payer: Anthem Medicaid |
$4,928.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,177.53
|
| Rate for Payer: Cash Price |
$7,165.08
|
| Rate for Payer: Cigna Commercial |
$11,894.04
|
| Rate for Payer: First Health Commercial |
$13,613.66
|
| Rate for Payer: Humana Commercial |
$12,180.64
|
| Rate for Payer: Humana KY Medicaid |
$4,928.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,978.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,750.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,575.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,299.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,027.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,610.55
|
| Rate for Payer: Ohio Health Group HMO |
$10,747.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,464.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,467.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,887.82
|
| Rate for Payer: PHCS Commercial |
$13,756.96
|
| Rate for Payer: United Healthcare All Payer |
$12,610.55
|
|
|
RF ACET MH SZ 60G
|
Facility
|
IP
|
$14,330.17
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,299.05 |
| Max. Negotiated Rate |
$13,756.96 |
| Rate for Payer: Aetna Commercial |
$11,034.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,177.53
|
| Rate for Payer: Cash Price |
$7,165.08
|
| Rate for Payer: Cigna Commercial |
$11,894.04
|
| Rate for Payer: First Health Commercial |
$13,613.66
|
| Rate for Payer: Humana Commercial |
$12,180.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,750.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,575.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,299.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,610.55
|
| Rate for Payer: Ohio Health Group HMO |
$10,747.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,464.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,467.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,887.82
|
| Rate for Payer: PHCS Commercial |
$13,756.96
|
| Rate for Payer: United Healthcare All Payer |
$12,610.55
|
|
|
RF ACET MH SZ 60G
|
Facility
|
OP
|
$14,330.17
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,299.05 |
| Max. Negotiated Rate |
$13,756.96 |
| Rate for Payer: Aetna Commercial |
$11,034.23
|
| Rate for Payer: Anthem Medicaid |
$4,928.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,177.53
|
| Rate for Payer: Cash Price |
$7,165.08
|
| Rate for Payer: Cigna Commercial |
$11,894.04
|
| Rate for Payer: First Health Commercial |
$13,613.66
|
| Rate for Payer: Humana Commercial |
$12,180.64
|
| Rate for Payer: Humana KY Medicaid |
$4,928.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,978.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,750.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,575.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,299.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,027.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,610.55
|
| Rate for Payer: Ohio Health Group HMO |
$10,747.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,464.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,467.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,887.82
|
| Rate for Payer: PHCS Commercial |
$13,756.96
|
| Rate for Payer: United Healthcare All Payer |
$12,610.55
|
|
|
RF ACET MH SZ 62H
|
Facility
|
IP
|
$14,330.17
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,299.05 |
| Max. Negotiated Rate |
$13,756.96 |
| Rate for Payer: Aetna Commercial |
$11,034.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,177.53
|
| Rate for Payer: Cash Price |
$7,165.08
|
| Rate for Payer: Cigna Commercial |
$11,894.04
|
| Rate for Payer: First Health Commercial |
$13,613.66
|
| Rate for Payer: Humana Commercial |
$12,180.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,750.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,575.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,299.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,610.55
|
| Rate for Payer: Ohio Health Group HMO |
$10,747.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,464.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,467.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,887.82
|
| Rate for Payer: PHCS Commercial |
$13,756.96
|
| Rate for Payer: United Healthcare All Payer |
$12,610.55
|
|
|
RF ACET MH SZ 62H
|
Facility
|
OP
|
$14,330.17
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,299.05 |
| Max. Negotiated Rate |
$13,756.96 |
| Rate for Payer: Aetna Commercial |
$11,034.23
|
| Rate for Payer: Anthem Medicaid |
$4,928.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,177.53
|
| Rate for Payer: Cash Price |
$7,165.08
|
| Rate for Payer: Cigna Commercial |
$11,894.04
|
| Rate for Payer: First Health Commercial |
$13,613.66
|
| Rate for Payer: Humana Commercial |
$12,180.64
|
| Rate for Payer: Humana KY Medicaid |
$4,928.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,978.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,750.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,575.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,299.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,027.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,610.55
|
| Rate for Payer: Ohio Health Group HMO |
$10,747.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,464.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,467.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,887.82
|
| Rate for Payer: PHCS Commercial |
$13,756.96
|
| Rate for Payer: United Healthcare All Payer |
$12,610.55
|
|
