|
SKN SUB GRFT F/N/HF/G CH AD(T
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS 15278
|
| Hospital Charge Code |
761T0198
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$11.83 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem Medicaid |
$31.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70.98
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Humana KY Medicaid |
$31.29
|
| Rate for Payer: Kentucky WC Medicaid |
$31.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$31.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28.21
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
SKN SUB GRFT T/A/L CHILD ADD
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
76100193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$442.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$477.25
|
| Rate for Payer: First Health Commercial |
$546.25
|
| Rate for Payer: Humana Commercial |
$488.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$471.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$424.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$506.00
|
| Rate for Payer: Ohio Health Group HMO |
$431.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.25
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
SKN SUB GRFT T/A/L CHILD ADD
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
76100193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$74.75 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna Commercial |
$442.75
|
| Rate for Payer: Anthem Medicaid |
$197.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$448.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$477.25
|
| Rate for Payer: First Health Commercial |
$546.25
|
| Rate for Payer: Humana Commercial |
$488.75
|
| Rate for Payer: Humana KY Medicaid |
$197.74
|
| Rate for Payer: Kentucky WC Medicaid |
$199.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$471.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$424.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$172.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$201.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$506.00
|
| Rate for Payer: Ohio Health Group HMO |
$431.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$115.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$74.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$178.25
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
SKN SUB GRFT T/A/L CHILD ADD
|
Professional
|
Both
|
$575.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
76100193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$575.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$35.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$575.00
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cash Price |
$287.50
|
| Rate for Payer: Cigna Commercial |
$75.03
|
| Rate for Payer: Healthspan PPO |
$62.80
|
| Rate for Payer: Humana Medicaid |
$35.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$36.33
|
| Rate for Payer: Molina Healthcare Passport |
$35.62
|
| Rate for Payer: Multiplan PHCS |
$345.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$402.50
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.98
|
|
|
SKN SUB GRFT T/A/L CHILD AD(P
|
Professional
|
Both
|
$150.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
761P0193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$23.19 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$35.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$150.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cash Price |
$75.00
|
| Rate for Payer: Cigna Commercial |
$75.03
|
| Rate for Payer: Healthspan PPO |
$62.80
|
| Rate for Payer: Humana Medicaid |
$35.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$36.33
|
| Rate for Payer: Molina Healthcare Passport |
$35.62
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$105.00
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$35.98
|
|
|
SKN SUB GRFT T/A/L CHILD AD(T
|
Facility
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
761T0193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$85.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.75
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
SKN SUB GRFT T/A/L CHILD AD(T
|
Facility
|
OP
|
$425.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
761T0193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$55.25 |
| Max. Negotiated Rate |
$408.00 |
| Rate for Payer: Aetna Commercial |
$327.25
|
| Rate for Payer: Anthem Medicaid |
$146.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$331.50
|
| Rate for Payer: Cash Price |
$212.50
|
| Rate for Payer: Cigna Commercial |
$352.75
|
| Rate for Payer: First Health Commercial |
$403.75
|
| Rate for Payer: Humana Commercial |
$361.25
|
| Rate for Payer: Humana KY Medicaid |
$146.16
|
| Rate for Payer: Kentucky WC Medicaid |
$147.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$348.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$313.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.00
|
| Rate for Payer: Ohio Health Group HMO |
$318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$85.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$55.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$131.75
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
SKSB FCE/NK/HF/G>=100SCM LC
|
Professional
|
Both
|
$2,900.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
76100197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$2,900.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$173.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,900.00
|
| Rate for Payer: Cash Price |
$1,450.00
|
| Rate for Payer: Cash Price |
$1,450.00
|
| Rate for Payer: Cigna Commercial |
$366.96
|
| Rate for Payer: Healthspan PPO |
$271.24
|
| Rate for Payer: Humana Medicaid |
$173.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$270.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.37
|
| Rate for Payer: Molina Healthcare Passport |
$173.89
|
| Rate for Payer: Multiplan PHCS |
$1,740.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,030.00
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.63
|
|
|
SKSB FCE/NK/HF/G>=100SCM LC
|
Facility
|
OP
|
$2,900.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
76100197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$377.00 |
| Max. Negotiated Rate |
$2,784.00 |
| Rate for Payer: Aetna Commercial |
$2,233.00
|
| Rate for Payer: Anthem Medicaid |
$997.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,262.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,450.00
|
| Rate for Payer: Cash Price |
$1,450.00
|
| Rate for Payer: Cigna Commercial |
$2,407.00
|
| Rate for Payer: First Health Commercial |
$2,755.00
|
| Rate for Payer: Humana Commercial |
$2,465.00
|
| Rate for Payer: Humana KY Medicaid |
$997.31
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,007.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,378.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,140.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,017.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,552.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$580.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$377.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$899.00
|
| Rate for Payer: PHCS Commercial |
$2,784.00
|
| Rate for Payer: United Healthcare All Payer |
$2,552.00
|
|
|
SKSB FCE/NK/HF/G>=100SCM LC
|
Facility
|
IP
|
$2,900.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
76100197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$377.00 |
| Max. Negotiated Rate |
$2,784.00 |
| Rate for Payer: Aetna Commercial |
$2,233.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,262.00
|
| Rate for Payer: Cash Price |
$1,450.00
|
| Rate for Payer: Cigna Commercial |
$2,407.00
|
| Rate for Payer: First Health Commercial |
$2,755.00
|
| Rate for Payer: Humana Commercial |
$2,465.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,378.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,140.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$870.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,552.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$580.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$377.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$899.00
|
| Rate for Payer: PHCS Commercial |
$2,784.00
|
| Rate for Payer: United Healthcare All Payer |
$2,552.00
|
|
|
SKSB FCE/NK/HF/G>=100SCM LC(P
|
Professional
|
Both
|
$576.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
761P0197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$114.72 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$173.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$576.00
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna Commercial |
$366.96
|
| Rate for Payer: Healthspan PPO |
$271.24
|
| Rate for Payer: Humana Medicaid |
$173.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$270.27
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$177.37
|
| Rate for Payer: Molina Healthcare Passport |
$173.89
|
| Rate for Payer: Multiplan PHCS |
$345.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$403.20
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$175.63
|
|
|
SKSB FCE/NK/HF/G>=100SCM LC(T
|
Facility
|
OP
|
$2,324.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
761T0197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$302.12 |
| Max. Negotiated Rate |
$2,231.04 |
| Rate for Payer: Aetna Commercial |
$1,789.48
|
| Rate for Payer: Anthem Medicaid |
$799.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,812.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,162.00
|
| Rate for Payer: Cash Price |
$1,162.00
|
| Rate for Payer: Cigna Commercial |
$1,928.92
|
| Rate for Payer: First Health Commercial |
$2,207.80
|
| Rate for Payer: Humana Commercial |
$1,975.40
|
| Rate for Payer: Humana KY Medicaid |
$799.22
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$807.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,905.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,715.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$815.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,045.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,743.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$302.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$720.44
|
| Rate for Payer: PHCS Commercial |
$2,231.04
|
| Rate for Payer: United Healthcare All Payer |
$2,045.12
|
|
|
SKSB FCE/NK/HF/G>=100SCM LC(T
|
Facility
|
IP
|
$2,324.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
761T0197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$302.12 |
| Max. Negotiated Rate |
$2,231.04 |
| Rate for Payer: Aetna Commercial |
$1,789.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,812.72
|
| Rate for Payer: Cash Price |
$1,162.00
|
| Rate for Payer: Cigna Commercial |
$1,928.92
|
| Rate for Payer: First Health Commercial |
$2,207.80
|
| Rate for Payer: Humana Commercial |
$1,975.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,905.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,715.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$697.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,045.12
|
| Rate for Payer: Ohio Health Group HMO |
$1,743.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$302.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$720.44
|
| Rate for Payer: PHCS Commercial |
$2,231.04
|
| Rate for Payer: United Healthcare All Payer |
$2,045.12
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
25002485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
63600073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
25002485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
636T0073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
63600073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
63600073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1,750.00 |
| Rate for Payer: Aetna Commercial |
$1,138.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,750.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,225.00
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
|
|
SKYLA 13.5 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
636T0073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYRIZI 1mg(600mg SDV)
|
Facility
|
IP
|
$55,152.42
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
25004311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,169.81 |
| Max. Negotiated Rate |
$52,946.32 |
| Rate for Payer: Aetna Commercial |
$42,467.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43,018.89
|
| Rate for Payer: Cash Price |
$27,576.21
|
| Rate for Payer: Cigna Commercial |
$45,776.51
|
| Rate for Payer: First Health Commercial |
$52,394.80
|
| Rate for Payer: Humana Commercial |
$46,879.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45,224.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40,702.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,545.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$48,534.13
|
| Rate for Payer: Ohio Health Group HMO |
$41,364.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,030.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,169.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,097.25
|
| Rate for Payer: PHCS Commercial |
$52,946.32
|
| Rate for Payer: United Healthcare All Payer |
$48,534.13
|
|
|
SKYRIZI 1mg(600mg SDV)
|
Facility
|
OP
|
$55,152.42
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
25004311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.36 |
| Max. Negotiated Rate |
$52,946.32 |
| Rate for Payer: Aetna Commercial |
$42,467.36
|
| Rate for Payer: Anthem Medicaid |
$18,966.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$43,018.89
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21.51
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.74
|
| Rate for Payer: Cash Price |
$27,576.21
|
| Rate for Payer: Cash Price |
$27,576.21
|
| Rate for Payer: Cigna Commercial |
$45,776.51
|
| Rate for Payer: First Health Commercial |
$52,394.80
|
| Rate for Payer: Humana Commercial |
$46,879.56
|
| Rate for Payer: Humana KY Medicaid |
$18,966.92
|
| Rate for Payer: Humana Medicare Advantage |
$15.36
|
| Rate for Payer: Kentucky WC Medicaid |
$19,159.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$45,224.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40,702.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,347.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$48,534.13
|
| Rate for Payer: Ohio Health Group HMO |
$41,364.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,030.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,169.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,097.25
|
| Rate for Payer: PHCS Commercial |
$52,946.32
|
| Rate for Payer: United Healthcare All Payer |
$48,534.13
|
|
|
SLEDGEHAMMER
|
Professional
|
Both
|
$95.00
|
|
| Hospital Charge Code |
22200123
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$95.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$95.00
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Multiplan PHCS |
$57.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.50
|
| Rate for Payer: UHCCP Medicaid |
$33.25
|
|
|
SLEEP LATENCY
|
Facility
|
IP
|
$3,260.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$423.80 |
| Max. Negotiated Rate |
$3,129.60 |
| Rate for Payer: Aetna Commercial |
$2,510.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,542.80
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cigna Commercial |
$2,705.80
|
| Rate for Payer: First Health Commercial |
$3,097.00
|
| Rate for Payer: Humana Commercial |
$2,771.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,673.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,405.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$978.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,868.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,445.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$652.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$423.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,010.60
|
| Rate for Payer: PHCS Commercial |
$3,129.60
|
| Rate for Payer: United Healthcare All Payer |
$2,868.80
|
|
|
SLEEP LATENCY
|
Professional
|
Both
|
$3,260.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$73.98 |
| Max. Negotiated Rate |
$3,260.00 |
| Rate for Payer: Aetna Commercial |
$641.16
|
| Rate for Payer: Anthem Medicaid |
$213.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,260.00
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cigna Commercial |
$959.14
|
| Rate for Payer: Healthspan PPO |
$560.73
|
| Rate for Payer: Humana Medicaid |
$213.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.17
|
| Rate for Payer: Molina Healthcare Passport |
$213.89
|
| Rate for Payer: Multiplan PHCS |
$1,956.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,282.00
|
| Rate for Payer: UHCCP Medicaid |
$1,141.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.03
|
|
