|
RUQ BILTREE GB LIV PANC CBDLTD
|
Facility
|
IP
|
$1,042.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0018
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$312.60 |
| Max. Negotiated Rate |
$1,000.32 |
| Rate for Payer: Aetna Commercial |
$802.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$812.76
|
| Rate for Payer: Cash Price |
$521.00
|
| Rate for Payer: Cigna Commercial |
$864.86
|
| Rate for Payer: First Health Commercial |
$989.90
|
| Rate for Payer: Humana Commercial |
$885.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$854.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$769.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$916.96
|
| Rate for Payer: Ohio Health Group HMO |
$781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$833.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$906.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$718.98
|
| Rate for Payer: PHCS Commercial |
$1,000.32
|
| Rate for Payer: United Healthcare All Payer |
$916.96
|
|
|
RUXIENCE 10mg (100mg Vial)
|
Facility
|
OP
|
$3,906.56
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$3,750.30 |
| Rate for Payer: Aetna Commercial |
$3,008.05
|
| Rate for Payer: Anthem Medicaid |
$1,343.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$26.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,047.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$37.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.77
|
| Rate for Payer: Cash Price |
$1,953.28
|
| Rate for Payer: Cash Price |
$1,953.28
|
| Rate for Payer: Cigna Commercial |
$3,242.44
|
| Rate for Payer: First Health Commercial |
$3,711.23
|
| Rate for Payer: Humana Commercial |
$3,320.58
|
| Rate for Payer: Humana KY Medicaid |
$1,343.47
|
| Rate for Payer: Humana Medicare Advantage |
$26.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,357.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,203.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,883.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,370.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,437.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,929.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,125.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,398.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,695.53
|
| Rate for Payer: PHCS Commercial |
$3,750.30
|
| Rate for Payer: United Healthcare All Payer |
$3,437.77
|
|
|
RUXIENCE 10mg (100mg Vial)
|
Facility
|
IP
|
$3,906.56
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003980
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,171.97 |
| Max. Negotiated Rate |
$3,750.30 |
| Rate for Payer: Aetna Commercial |
$3,008.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,047.12
|
| Rate for Payer: Cash Price |
$1,953.28
|
| Rate for Payer: Cigna Commercial |
$3,242.44
|
| Rate for Payer: First Health Commercial |
$3,711.23
|
| Rate for Payer: Humana Commercial |
$3,320.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,203.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,883.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,171.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,437.77
|
| Rate for Payer: Ohio Health Group HMO |
$2,929.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,125.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,398.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,695.53
|
| Rate for Payer: PHCS Commercial |
$3,750.30
|
| Rate for Payer: United Healthcare All Payer |
$3,437.77
|
|
|
RUXIENCE 10mg (500mg Vial)
|
Facility
|
IP
|
$19,532.80
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003979
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,859.84 |
| Max. Negotiated Rate |
$18,751.49 |
| Rate for Payer: Aetna Commercial |
$15,040.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,235.58
|
| Rate for Payer: Cash Price |
$9,766.40
|
| Rate for Payer: Cigna Commercial |
$16,212.22
|
| Rate for Payer: First Health Commercial |
$18,556.16
|
| Rate for Payer: Humana Commercial |
$16,602.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,016.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,415.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,859.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,188.86
|
| Rate for Payer: Ohio Health Group HMO |
$14,649.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,626.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,993.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,477.63
|
| Rate for Payer: PHCS Commercial |
$18,751.49
|
| Rate for Payer: United Healthcare All Payer |
$17,188.86
|
|
|
RUXIENCE 10mg (500mg Vial)
|
Facility
|
OP
|
$19,532.80
|
|
|
Service Code
|
HCPCS Q5119
|
| Hospital Charge Code |
25003979
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.50 |
| Max. Negotiated Rate |
$18,751.49 |
| Rate for Payer: Aetna Commercial |
$15,040.26
|
| Rate for Payer: Anthem Medicaid |
$6,717.33
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$26.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,235.58
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$37.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.77
|
| Rate for Payer: Cash Price |
$9,766.40
|
| Rate for Payer: Cash Price |
$9,766.40
|
| Rate for Payer: Cigna Commercial |
$16,212.22
|
| Rate for Payer: First Health Commercial |
$18,556.16
|
| Rate for Payer: Humana Commercial |
$16,602.88
|
| Rate for Payer: Humana KY Medicaid |
$6,717.33
|
| Rate for Payer: Humana Medicare Advantage |
$26.50
|
| Rate for Payer: Kentucky WC Medicaid |
$6,785.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,016.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,415.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,852.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,188.86
|
| Rate for Payer: Ohio Health Group HMO |
$14,649.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,626.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,993.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,477.63
|
| Rate for Payer: PHCS Commercial |
$18,751.49
|
| Rate for Payer: United Healthcare All Payer |
$17,188.86
|
|
|
RV1 VACC 2 DOSE LIVE ORAL
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
77000030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV1 VACC 2 DOSE LIVE ORAL
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
77000030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.59
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV1 VACC 2 DOSE LIVE ORAL
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
77000030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$215.96 |
| Rate for Payer: Anthem Medicaid |
$106.57
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$106.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$215.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$108.70
|
| Rate for Payer: Molina Healthcare Passport |
$106.57
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$52.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$107.64
|
|
|
RV1 VACC 2 DOSE LIVE ORAL(T
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
770T0030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem Medicaid |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Humana KY Medicaid |
$51.59
|
| Rate for Payer: Kentucky WC Medicaid |
$52.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV1 VACC 2 DOSE LIVE ORAL(T
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
HCPCS 90681
|
| Hospital Charge Code |
770T0030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$144.00 |
| Rate for Payer: Aetna Commercial |
$115.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$117.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$124.50
|
| Rate for Payer: First Health Commercial |
$142.50
|
| Rate for Payer: Humana Commercial |
$127.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$123.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$110.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$45.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$132.00
|
| Rate for Payer: Ohio Health Group HMO |
$112.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.50
|
| Rate for Payer: PHCS Commercial |
$144.00
|
| Rate for Payer: United Healthcare All Payer |
$132.00
|
|
|
RV5 VACC 3 DOSE LIVE ORAL
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
77000029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RV5 VACC 3 DOSE LIVE ORAL
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
77000029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RV5 VACC 3 DOSE LIVE ORAL
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
77000029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$149.34 |
| Rate for Payer: Anthem Medicaid |
$75.20
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Healthspan PPO |
$83.88
|
| Rate for Payer: Humana Medicaid |
$75.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$149.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$76.70
|
| Rate for Payer: Molina Healthcare Passport |
$75.20
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$75.95
|
|
|
RV5 VACC 3 DOSE LIVE ORAL(T
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
770T0029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RV5 VACC 3 DOSE LIVE ORAL(T
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 90680
|
| Hospital Charge Code |
770T0029
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RVP EXT/SARS COV-2
|
Facility
|
OP
|
$1,740.00
|
|
|
Service Code
|
HCPCS 0223U
|
| Hospital Charge Code |
30001807
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$416.78 |
| Max. Negotiated Rate |
$1,670.40 |
| Rate for Payer: Aetna Commercial |
$1,339.80
|
| Rate for Payer: Anthem Medicaid |
$416.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$416.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$583.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.78
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cigna Commercial |
$1,444.20
|
| Rate for Payer: First Health Commercial |
$1,653.00
|
| Rate for Payer: Humana Commercial |
$1,479.00
|
| Rate for Payer: Humana KY Medicaid |
$416.78
|
| Rate for Payer: Humana Medicare Advantage |
$416.78
|
| Rate for Payer: Kentucky WC Medicaid |
$420.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,426.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,284.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$500.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,531.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,513.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,200.60
|
| Rate for Payer: PHCS Commercial |
$1,670.40
|
| Rate for Payer: United Healthcare All Payer |
$1,531.20
|
|
|
RVP EXT/SARS COV-2
|
Professional
|
Both
|
$1,740.00
|
|
|
Service Code
|
HCPCS 0223U
|
| Hospital Charge Code |
30001807
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$250.07 |
| Max. Negotiated Rate |
$1,044.00 |
| Rate for Payer: Ambetter Exchange |
$416.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$416.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$416.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$500.14
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$416.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$416.78
|
| Rate for Payer: Multiplan PHCS |
$1,044.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$541.81
|
| Rate for Payer: UHCCP Medicaid |
$609.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$250.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$416.78
|
|
|
RVP EXT/SARS COV-2
|
Facility
|
IP
|
$1,740.00
|
|
|
Service Code
|
HCPCS 0223U
|
| Hospital Charge Code |
30001807
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$522.00 |
| Max. Negotiated Rate |
$1,670.40 |
| Rate for Payer: Aetna Commercial |
$1,339.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,397.22
|
| Rate for Payer: Cash Price |
$870.00
|
| Rate for Payer: Cigna Commercial |
$1,444.20
|
| Rate for Payer: First Health Commercial |
$1,653.00
|
| Rate for Payer: Humana Commercial |
$1,479.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,426.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,284.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$522.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,531.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,513.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,200.60
|
| Rate for Payer: PHCS Commercial |
$1,670.40
|
| Rate for Payer: United Healthcare All Payer |
$1,531.20
|
|
|
RX TREK DILATION CATH 1.50* 12
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
RX TREK DILATION CATH 1.50* 12
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
RX TREK DILATION CATH 2.50* 12
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
RX TREK DILATION CATH 2.50* 12
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
RX TREK DILATION CATH 2.50* 15
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
RX TREK DILATION CATH 2.50* 15
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
RX TREK DILATION CATH 2.50* 20
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
