|
RX VISION STENT 4*12
|
Facility
|
OP
|
$4,025.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,207.50 |
| Max. Negotiated Rate |
$3,864.00 |
| Rate for Payer: Aetna Commercial |
$3,099.25
|
| Rate for Payer: Anthem Medicaid |
$1,384.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,139.50
|
| Rate for Payer: Cash Price |
$2,012.50
|
| Rate for Payer: Cigna Commercial |
$3,340.75
|
| Rate for Payer: First Health Commercial |
$3,823.75
|
| Rate for Payer: Humana Commercial |
$3,421.25
|
| Rate for Payer: Humana KY Medicaid |
$1,384.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,398.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,300.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,970.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,207.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,411.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,542.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,018.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,501.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,777.25
|
| Rate for Payer: PHCS Commercial |
$3,864.00
|
| Rate for Payer: United Healthcare All Payer |
$3,542.00
|
|
|
RX VISION STENT 4*15
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
RX VISION STENT 4*15
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
RX VISION STENT 4*18
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
RX VISION STENT 4*18
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
RX VISION STENT 4*23
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
RX VISION STENT 4*23
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
RX VISION STENT 4*28
|
Facility
|
IP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
RX VISION STENT 4*28
|
Facility
|
OP
|
$4,906.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,471.88 |
| Max. Negotiated Rate |
$4,710.00 |
| Rate for Payer: Aetna Commercial |
$3,777.81
|
| Rate for Payer: Anthem Medicaid |
$1,687.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,826.88
|
| Rate for Payer: Cash Price |
$2,453.12
|
| Rate for Payer: Cigna Commercial |
$4,072.19
|
| Rate for Payer: First Health Commercial |
$4,660.94
|
| Rate for Payer: Humana Commercial |
$4,170.31
|
| Rate for Payer: Humana KY Medicaid |
$1,687.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,620.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,471.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,679.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,268.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.31
|
| Rate for Payer: PHCS Commercial |
$4,710.00
|
| Rate for Payer: United Healthcare All Payer |
$4,317.50
|
|
|
RX VISION STENT 4*8
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
RX VISION STENT 4*8
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
RYE GRASS IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000639
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
RYE GRASS IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000639
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
RYSTIGGO 1MG (280MG/2ML SDV)
|
Facility
|
IP
|
$33,384.68
|
|
|
Service Code
|
HCPCS J9333
|
| Hospital Charge Code |
25004488
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,015.40 |
| Max. Negotiated Rate |
$32,049.29 |
| Rate for Payer: Aetna Commercial |
$25,706.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,040.05
|
| Rate for Payer: Cash Price |
$16,692.34
|
| Rate for Payer: Cigna Commercial |
$27,709.28
|
| Rate for Payer: First Health Commercial |
$31,715.45
|
| Rate for Payer: Humana Commercial |
$28,376.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,375.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,637.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,015.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,378.52
|
| Rate for Payer: Ohio Health Group HMO |
$25,038.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,707.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,044.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,035.43
|
| Rate for Payer: PHCS Commercial |
$32,049.29
|
| Rate for Payer: United Healthcare All Payer |
$29,378.52
|
|
|
RYSTIGGO 1MG (280MG/2ML SDV)
|
Facility
|
OP
|
$33,384.68
|
|
|
Service Code
|
HCPCS J9333
|
| Hospital Charge Code |
25004488
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.16 |
| Max. Negotiated Rate |
$32,049.29 |
| Rate for Payer: Aetna Commercial |
$25,706.20
|
| Rate for Payer: Anthem Medicaid |
$11,480.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$23.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,040.05
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$32.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.27
|
| Rate for Payer: Cash Price |
$16,692.34
|
| Rate for Payer: Cash Price |
$16,692.34
|
| Rate for Payer: Cigna Commercial |
$27,709.28
|
| Rate for Payer: First Health Commercial |
$31,715.45
|
| Rate for Payer: Humana Commercial |
$28,376.98
|
| Rate for Payer: Humana KY Medicaid |
$11,480.99
|
| Rate for Payer: Humana Medicare Advantage |
$23.16
|
| Rate for Payer: Kentucky WC Medicaid |
$11,597.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,375.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,637.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,711.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,378.52
|
| Rate for Payer: Ohio Health Group HMO |
$25,038.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26,707.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,044.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,035.43
|
| Rate for Payer: PHCS Commercial |
$32,049.29
|
| Rate for Payer: United Healthcare All Payer |
$29,378.52
|
|
|
RYTHMOL (PROPAFENON 150MG/1TAB
|
Facility
|
OP
|
$4.59
|
|
|
Service Code
|
NDC 591058201
|
| Hospital Charge Code |
25001352
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
RYTHMOL (PROPAFENON 150MG/1TAB
|
Facility
|
IP
|
$4.59
|
|
|
Service Code
|
NDC 591058201
|
| Hospital Charge Code |
25001352
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.41 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.81
|
| Rate for Payer: First Health Commercial |
$4.36
|
| Rate for Payer: Humana Commercial |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.04
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.41
|
| Rate for Payer: United Healthcare All Payer |
$4.04
|
|
|
RYTHMOL(PROPAFENONE HCL)225MGT
|
Facility
|
IP
|
$4.60
|
|
|
Service Code
|
NDC 62559023101
|
| Hospital Charge Code |
25001356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
RYTHMOL(PROPAFENONE HCL)225MGT
|
Facility
|
OP
|
$4.60
|
|
|
Service Code
|
NDC 62559023101
|
| Hospital Charge Code |
25001356
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$4.42 |
| Rate for Payer: Aetna Commercial |
$3.54
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cigna Commercial |
$3.82
|
| Rate for Payer: First Health Commercial |
$4.37
|
| Rate for Payer: Humana Commercial |
$3.91
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.05
|
| Rate for Payer: Ohio Health Group HMO |
$3.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.17
|
| Rate for Payer: PHCS Commercial |
$4.42
|
| Rate for Payer: United Healthcare All Payer |
$4.05
|
|
|
RYTHMOL SR 325 MG CAPSULE
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 68462040960
|
| Hospital Charge Code |
25001354
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
RYTHMOL SR 325 MG CAPSULE
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 68462040960
|
| Hospital Charge Code |
25001354
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.86
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cigna Commercial |
$4.11
|
| Rate for Payer: First Health Commercial |
$4.70
|
| Rate for Payer: Humana Commercial |
$4.21
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.36
|
| Rate for Payer: Ohio Health Group HMO |
$3.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.42
|
| Rate for Payer: PHCS Commercial |
$4.75
|
| Rate for Payer: United Healthcare All Payer |
$4.36
|
|
|
RYTHMOL SR (PROPAFENO) 225MG T
|
Facility
|
OP
|
$4.70
|
|
|
Service Code
|
NDC 68462040860
|
| Hospital Charge Code |
25001353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem Medicaid |
$1.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Humana KY Medicaid |
$1.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
RYTHMOL SR (PROPAFENO) 225MG T
|
Facility
|
IP
|
$4.70
|
|
|
Service Code
|
NDC 68462040860
|
| Hospital Charge Code |
25001353
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$4.51 |
| Rate for Payer: Aetna Commercial |
$3.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.67
|
| Rate for Payer: Cash Price |
$2.35
|
| Rate for Payer: Cigna Commercial |
$3.90
|
| Rate for Payer: First Health Commercial |
$4.46
|
| Rate for Payer: Humana Commercial |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.14
|
| Rate for Payer: Ohio Health Group HMO |
$3.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.24
|
| Rate for Payer: PHCS Commercial |
$4.51
|
| Rate for Payer: United Healthcare All Payer |
$4.14
|
|
|
SABER BALLOON 10*10*90
|
Facility
|
IP
|
$2,117.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$635.10 |
| Max. Negotiated Rate |
$2,032.32 |
| Rate for Payer: Aetna Commercial |
$1,630.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,651.26
|
| Rate for Payer: Cash Price |
$1,058.50
|
| Rate for Payer: Cigna Commercial |
$1,757.11
|
| Rate for Payer: First Health Commercial |
$2,011.15
|
| Rate for Payer: Humana Commercial |
$1,799.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,735.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,562.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$635.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,862.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,587.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,693.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,841.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,460.73
|
| Rate for Payer: PHCS Commercial |
$2,032.32
|
| Rate for Payer: United Healthcare All Payer |
$1,862.96
|
|
|
SABER BALLOON 10*10*90
|
Facility
|
OP
|
$2,117.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$635.10 |
| Max. Negotiated Rate |
$2,032.32 |
| Rate for Payer: Aetna Commercial |
$1,630.09
|
| Rate for Payer: Anthem Medicaid |
$728.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,651.26
|
| Rate for Payer: Cash Price |
$1,058.50
|
| Rate for Payer: Cigna Commercial |
$1,757.11
|
| Rate for Payer: First Health Commercial |
$2,011.15
|
| Rate for Payer: Humana Commercial |
$1,799.45
|
| Rate for Payer: Humana KY Medicaid |
$728.04
|
| Rate for Payer: Kentucky WC Medicaid |
$735.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,735.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,562.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$635.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$742.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,862.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,587.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,693.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,841.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,460.73
|
| Rate for Payer: PHCS Commercial |
$2,032.32
|
| Rate for Payer: United Healthcare All Payer |
$1,862.96
|
|
