|
SPLT THCKN SKN GRFT <100 SQ CM
|
Professional
|
Both
|
$6,280.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
76100175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.96 |
| Max. Negotiated Rate |
$6,280.96 |
| Rate for Payer: Aetna Commercial |
$1,031.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$365.96
|
| Rate for Payer: Anthem Medicaid |
$379.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,280.96
|
| Rate for Payer: Cash Price |
$3,140.48
|
| Rate for Payer: Cash Price |
$3,140.48
|
| Rate for Payer: Cigna Commercial |
$1,007.18
|
| Rate for Payer: Healthspan PPO |
$972.22
|
| Rate for Payer: Humana Medicaid |
$379.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$897.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$387.20
|
| Rate for Payer: Molina Healthcare Passport |
$379.61
|
| Rate for Payer: Multiplan PHCS |
$3,768.58
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,396.67
|
| Rate for Payer: UHCCP Medicaid |
$384.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.41
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Facility
|
OP
|
$6,280.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
76100175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$816.52 |
| Max. Negotiated Rate |
$6,029.72 |
| Rate for Payer: Aetna Commercial |
$4,836.34
|
| Rate for Payer: Anthem Medicaid |
$2,160.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,899.15
|
| 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 |
$3,140.48
|
| Rate for Payer: Cash Price |
$3,140.48
|
| Rate for Payer: Cigna Commercial |
$5,213.20
|
| Rate for Payer: First Health Commercial |
$5,966.91
|
| Rate for Payer: Humana Commercial |
$5,338.82
|
| Rate for Payer: Humana KY Medicaid |
$2,160.02
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,182.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,150.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,635.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,203.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,527.24
|
| Rate for Payer: Ohio Health Group HMO |
$4,710.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,256.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$816.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,947.10
|
| Rate for Payer: PHCS Commercial |
$6,029.72
|
| Rate for Payer: United Healthcare All Payer |
$5,527.24
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Professional
|
Both
|
$1,139.00
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
761P0175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.96 |
| Max. Negotiated Rate |
$1,139.00 |
| Rate for Payer: Aetna Commercial |
$1,031.79
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$365.96
|
| Rate for Payer: Anthem Medicaid |
$379.61
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,139.00
|
| Rate for Payer: Cash Price |
$569.50
|
| Rate for Payer: Cash Price |
$569.50
|
| Rate for Payer: Cigna Commercial |
$1,007.18
|
| Rate for Payer: Healthspan PPO |
$972.22
|
| Rate for Payer: Humana Medicaid |
$379.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$897.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$387.20
|
| Rate for Payer: Molina Healthcare Passport |
$379.61
|
| Rate for Payer: Multiplan PHCS |
$683.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$797.30
|
| Rate for Payer: UHCCP Medicaid |
$384.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.41
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Facility
|
OP
|
$5,141.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
761T0175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$668.45 |
| Max. Negotiated Rate |
$4,936.28 |
| Rate for Payer: Aetna Commercial |
$3,959.31
|
| Rate for Payer: Anthem Medicaid |
$1,768.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,010.73
|
| 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 |
$2,570.98
|
| Rate for Payer: Cash Price |
$2,570.98
|
| Rate for Payer: Cigna Commercial |
$4,267.83
|
| Rate for Payer: First Health Commercial |
$4,884.86
|
| Rate for Payer: Humana Commercial |
$4,370.67
|
| Rate for Payer: Humana KY Medicaid |
$1,768.32
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,786.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,216.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,794.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,803.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,524.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,856.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,028.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,594.01
|
| Rate for Payer: PHCS Commercial |
$4,936.28
|
| Rate for Payer: United Healthcare All Payer |
$4,524.92
|
|
|
SPLT THCKN SKN GRFT <100 SQ CM
|
Facility
|
IP
|
$5,141.96
|
|
|
Service Code
|
HCPCS 15100
|
| Hospital Charge Code |
761T0175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$668.45 |
| Max. Negotiated Rate |
$4,936.28 |
| Rate for Payer: Aetna Commercial |
$3,959.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,010.73
|
| Rate for Payer: Cash Price |
$2,570.98
|
| Rate for Payer: Cigna Commercial |
$4,267.83
|
| Rate for Payer: First Health Commercial |
$4,884.86
|
| Rate for Payer: Humana Commercial |
$4,370.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,216.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,794.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,542.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,524.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,856.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,028.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$668.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,594.01
|
| Rate for Payer: PHCS Commercial |
$4,936.28
|
| Rate for Payer: United Healthcare All Payer |
$4,524.92
|
|
|
SPORANOX 10MG/ML ORAL (10ML)
|
Facility
|
OP
|
$39.85
|
|
|
Service Code
|
NDC 50458029515
|
| Hospital Charge Code |
25001423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$38.26 |
| Rate for Payer: Aetna Commercial |
$30.68
|
| Rate for Payer: Anthem Medicaid |
$13.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.08
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Cigna Commercial |
$33.08
|
| Rate for Payer: First Health Commercial |
$37.86
|
| Rate for Payer: Humana Commercial |
$33.87
|
| Rate for Payer: Humana KY Medicaid |
$13.70
|
| Rate for Payer: Kentucky WC Medicaid |
$13.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.07
|
| Rate for Payer: Ohio Health Group HMO |
$29.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.35
|
| Rate for Payer: PHCS Commercial |
$38.26
|
| Rate for Payer: United Healthcare All Payer |
$35.07
|
|
|
SPORANOX 10MG/ML ORAL (10ML)
|
Facility
|
IP
|
$39.85
|
|
|
Service Code
|
NDC 50458029515
|
| Hospital Charge Code |
25001423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$38.26 |
| Rate for Payer: Aetna Commercial |
$30.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.08
|
| Rate for Payer: Cash Price |
$19.92
|
| Rate for Payer: Cigna Commercial |
$33.08
|
| Rate for Payer: First Health Commercial |
$37.86
|
| Rate for Payer: Humana Commercial |
$33.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.07
|
| Rate for Payer: Ohio Health Group HMO |
$29.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.35
|
| Rate for Payer: PHCS Commercial |
$38.26
|
| Rate for Payer: United Healthcare All Payer |
$35.07
|
|
|
SPORANOX (ITRACONAZ 100MG/1CAP
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 67877045430
|
| Hospital Charge Code |
25001422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
SPORANOX (ITRACONAZ 100MG/1CAP
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
NDC 67877045430
|
| Hospital Charge Code |
25001422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
SPORTS PHYSICAL
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
45000321
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.75
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
SPORTS PHYSICAL
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
45000321
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$19.25
|
| Rate for Payer: Anthem Medicaid |
$8.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19.50
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Cigna Commercial |
$20.75
|
| Rate for Payer: First Health Commercial |
$23.75
|
| Rate for Payer: Humana Commercial |
$21.25
|
| Rate for Payer: Humana KY Medicaid |
$8.60
|
| Rate for Payer: Kentucky WC Medicaid |
$8.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.00
|
| Rate for Payer: Ohio Health Group HMO |
$18.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.75
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
SPORTS PHYSICAL $25
|
Professional
|
Both
|
$25.00
|
|
| Hospital Charge Code |
76102596
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$25.00
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.50
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
|
|
SPORTS PHYSICAL $25 (P
|
Professional
|
Both
|
$25.00
|
|
| Hospital Charge Code |
761P2596
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$25.00
|
| Rate for Payer: Cash Price |
$12.50
|
| Rate for Payer: Multiplan PHCS |
$15.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$17.50
|
| Rate for Payer: UHCCP Medicaid |
$8.75
|
|
|
Spot TRL upto5 spot-PP#2/3 25%
|
Professional
|
Both
|
$127.00
|
|
| Hospital Charge Code |
22200678
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$44.45 |
| Max. Negotiated Rate |
$127.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$127.00
|
| Rate for Payer: Cash Price |
$63.50
|
| Rate for Payer: Multiplan PHCS |
$76.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.90
|
| Rate for Payer: UHCCP Medicaid |
$44.45
|
|
|
Spot TRL, up to 5 spots
|
Professional
|
Both
|
$200.00
|
|
| Hospital Charge Code |
22200660
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$70.00 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
|
|
Spot TRL upto5 spots-PP #1 50%
|
Professional
|
Both
|
$256.00
|
|
| Hospital Charge Code |
22200661
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$89.60 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$256.00
|
| Rate for Payer: Cash Price |
$128.00
|
| Rate for Payer: Multiplan PHCS |
$153.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$179.20
|
| Rate for Payer: UHCCP Medicaid |
$89.60
|
|
|
SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITH CC/MCC
|
Facility
|
IP
|
$11,312.15
|
|
|
Service Code
|
MSDRG 537
|
| Min. Negotiated Rate |
$7,676.10 |
| Max. Negotiated Rate |
$11,312.15 |
| Rate for Payer: Anthem Medicaid |
$7,676.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,080.11
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,312.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,908.15
|
| Rate for Payer: Humana KY Medicaid |
$7,676.10
|
| Rate for Payer: Humana Medicare Advantage |
$8,080.11
|
| Rate for Payer: Kentucky WC Medicaid |
$7,752.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,696.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,829.63
|
|
|
SPRAINS, STRAINS, AND DISLOCATIONS OF HIP, PELVIS AND THIGH WITHOUT CC/MCC
|
Facility
|
IP
|
$8,295.20
|
|
|
Service Code
|
MSDRG 538
|
| Min. Negotiated Rate |
$5,628.88 |
| Max. Negotiated Rate |
$8,295.20 |
| Rate for Payer: Anthem Medicaid |
$5,628.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,925.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,295.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,998.94
|
| Rate for Payer: Humana KY Medicaid |
$5,628.88
|
| Rate for Payer: Humana Medicare Advantage |
$5,925.14
|
| Rate for Payer: Kentucky WC Medicaid |
$5,685.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,110.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,741.46
|
|
|
SPRINTER LEGEND OTW 1.25*10
|
Facility
|
OP
|
$1,129.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.84 |
| Max. Negotiated Rate |
$1,084.32 |
| Rate for Payer: Aetna Commercial |
$869.72
|
| Rate for Payer: Anthem Medicaid |
$388.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.01
|
| Rate for Payer: Cash Price |
$564.75
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: First Health Commercial |
$1,073.02
|
| Rate for Payer: Humana Commercial |
$960.08
|
| Rate for Payer: Humana KY Medicaid |
$388.44
|
| Rate for Payer: Kentucky WC Medicaid |
$392.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$993.96
|
| Rate for Payer: Ohio Health Group HMO |
$847.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.14
|
| Rate for Payer: PHCS Commercial |
$1,084.32
|
| Rate for Payer: United Healthcare All Payer |
$993.96
|
|
|
SPRINTER LEGEND OTW 1.25*10
|
Facility
|
IP
|
$1,129.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.84 |
| Max. Negotiated Rate |
$1,084.32 |
| Rate for Payer: Ohio Health Choice Commercial |
$993.96
|
| Rate for Payer: Ohio Health Group HMO |
$847.12
|
| Rate for Payer: Aetna Commercial |
$869.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.01
|
| Rate for Payer: Cash Price |
$564.75
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: First Health Commercial |
$1,073.02
|
| Rate for Payer: Humana Commercial |
$960.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.14
|
| Rate for Payer: PHCS Commercial |
$1,084.32
|
| Rate for Payer: United Healthcare All Payer |
$993.96
|
|
|
SPRINTER LEGEND OTW 1.25*15
|
Facility
|
IP
|
$1,129.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.84 |
| Max. Negotiated Rate |
$1,084.32 |
| Rate for Payer: Aetna Commercial |
$869.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.01
|
| Rate for Payer: Cash Price |
$564.75
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: First Health Commercial |
$1,073.02
|
| Rate for Payer: Humana Commercial |
$960.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$993.96
|
| Rate for Payer: Ohio Health Group HMO |
$847.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.14
|
| Rate for Payer: PHCS Commercial |
$1,084.32
|
| Rate for Payer: United Healthcare All Payer |
$993.96
|
|
|
SPRINTER LEGEND OTW 1.25*15
|
Facility
|
OP
|
$1,129.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.84 |
| Max. Negotiated Rate |
$1,084.32 |
| Rate for Payer: Aetna Commercial |
$869.72
|
| Rate for Payer: Anthem Medicaid |
$388.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.01
|
| Rate for Payer: Cash Price |
$564.75
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: First Health Commercial |
$1,073.02
|
| Rate for Payer: Humana Commercial |
$960.08
|
| Rate for Payer: Humana KY Medicaid |
$388.44
|
| Rate for Payer: Kentucky WC Medicaid |
$392.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$396.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$993.96
|
| Rate for Payer: Ohio Health Group HMO |
$847.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.14
|
| Rate for Payer: PHCS Commercial |
$1,084.32
|
| Rate for Payer: United Healthcare All Payer |
$993.96
|
|
|
SPRINTER LEGEND OTW 1.25*20
|
Facility
|
OP
|
$1,547.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$1,485.60 |
| Rate for Payer: Aetna Commercial |
$1,191.58
|
| Rate for Payer: Anthem Medicaid |
$532.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,207.05
|
| Rate for Payer: Cash Price |
$773.75
|
| Rate for Payer: Cigna Commercial |
$1,284.42
|
| Rate for Payer: First Health Commercial |
$1,470.12
|
| Rate for Payer: Humana Commercial |
$1,315.38
|
| Rate for Payer: Humana KY Medicaid |
$532.19
|
| Rate for Payer: Kentucky WC Medicaid |
$537.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,268.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,142.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$542.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,361.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,160.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$479.72
|
| Rate for Payer: PHCS Commercial |
$1,485.60
|
| Rate for Payer: United Healthcare All Payer |
$1,361.80
|
|
|
SPRINTER LEGEND OTW 1.25*20
|
Facility
|
IP
|
$1,547.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$1,485.60 |
| Rate for Payer: Aetna Commercial |
$1,191.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,207.05
|
| Rate for Payer: Cash Price |
$773.75
|
| Rate for Payer: Cigna Commercial |
$1,284.42
|
| Rate for Payer: First Health Commercial |
$1,470.12
|
| Rate for Payer: Humana Commercial |
$1,315.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,268.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,142.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$464.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,361.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,160.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$309.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$201.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$479.72
|
| Rate for Payer: PHCS Commercial |
$1,485.60
|
| Rate for Payer: United Healthcare All Payer |
$1,361.80
|
|
|
SPRINTER LEGEND RX 1.25*10
|
Facility
|
IP
|
$1,129.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.84 |
| Max. Negotiated Rate |
$1,084.32 |
| Rate for Payer: Aetna Commercial |
$869.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$881.01
|
| Rate for Payer: Cash Price |
$564.75
|
| Rate for Payer: Cigna Commercial |
$937.48
|
| Rate for Payer: First Health Commercial |
$1,073.02
|
| Rate for Payer: Humana Commercial |
$960.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$926.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$833.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$338.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$993.96
|
| Rate for Payer: Ohio Health Group HMO |
$847.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$350.14
|
| Rate for Payer: PHCS Commercial |
$1,084.32
|
| Rate for Payer: United Healthcare All Payer |
$993.96
|
|
