|
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 |
$172.50 |
| 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 |
$199.75
|
| 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: 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 |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$500.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.75
|
| 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
|
IP
|
$575.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
76100193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$172.50 |
| 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 |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$500.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$396.75
|
| Rate for Payer: PHCS Commercial |
$552.00
|
| Rate for Payer: United Healthcare All Payer |
$506.00
|
|
|
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 |
$90.00 |
| Rate for Payer: Ambetter Exchange |
$41.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$23.19
|
| Rate for Payer: Anthem Medicaid |
$55.00
|
| Rate for Payer: Buckeye Individual/Medicaid |
$41.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$41.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.85
|
| 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 |
$55.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.99
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$41.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$56.10
|
| Rate for Payer: Molina Healthcare Passport |
$55.00
|
| Rate for Payer: Multiplan PHCS |
$90.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$54.00
|
| Rate for Payer: UHCCP Medicaid |
$24.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$55.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$41.54
|
|
|
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 |
$127.50 |
| 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 |
$147.65
|
| 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 |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| 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
|
IP
|
$425.00
|
|
|
Service Code
|
HCPCS 15274
|
| Hospital Charge Code |
761T0193
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$127.50 |
| 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 |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$369.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.25
|
| Rate for Payer: PHCS Commercial |
$408.00
|
| Rate for Payer: United Healthcare All Payer |
$374.00
|
|
|
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 |
$997.31 |
| 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 |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,262.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$2,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,523.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,001.00
|
| 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 |
$870.00 |
| 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 |
$2,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,523.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,001.00
|
| 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
|
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 |
$1,740.00 |
| Rate for Payer: Ambetter Exchange |
$210.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$236.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$210.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$210.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$253.04
|
| 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 |
$236.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$270.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$210.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.89
|
| Rate for Payer: Molina Healthcare Passport |
$236.17
|
| Rate for Payer: Multiplan PHCS |
$1,740.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$274.13
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
|
|
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 |
$366.96 |
| Rate for Payer: Ambetter Exchange |
$210.87
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$114.72
|
| Rate for Payer: Anthem Medicaid |
$236.17
|
| Rate for Payer: Buckeye Individual/Medicaid |
$210.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$210.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$253.04
|
| 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 |
$236.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$270.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$210.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$240.89
|
| Rate for Payer: Molina Healthcare Passport |
$236.17
|
| Rate for Payer: Multiplan PHCS |
$345.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$274.13
|
| Rate for Payer: UHCCP Medicaid |
$120.46
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$238.53
|
| Rate for Payer: Wellcare Medicare Advantage |
$210.87
|
|
|
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 |
$697.20 |
| 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 |
$1,859.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,021.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,603.56
|
| 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
|
OP
|
$2,324.00
|
|
|
Service Code
|
HCPCS 15277
|
| Hospital Charge Code |
761T0197
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$799.22 |
| Max. Negotiated Rate |
$2,366.24 |
| Rate for Payer: Aetna Commercial |
$1,789.48
|
| Rate for Payer: Anthem Medicaid |
$799.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,812.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| 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 |
$1,690.17
|
| 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 |
$2,028.20
|
| 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 |
$1,859.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,021.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,603.56
|
| 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 |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| 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 |
$601.83
|
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
$525.00 |
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
636T0073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
$1,225.00 |
| Rate for Payer: Aetna Commercial |
$1,138.15
|
| 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
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
63600073
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| 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 |
$601.83
|
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| 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 |
$601.83
|
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| 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 |
$525.00 |
| 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 |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
SKYRIZI 1mg(600mg SDV)
|
Facility
|
IP
|
$56,531.22
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
25004311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16,959.37 |
| Max. Negotiated Rate |
$54,269.97 |
| Rate for Payer: Aetna Commercial |
$43,529.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44,094.35
|
| Rate for Payer: Cash Price |
$28,265.61
|
| Rate for Payer: Cigna Commercial |
$46,920.91
|
| Rate for Payer: First Health Commercial |
$53,704.66
|
| Rate for Payer: Humana Commercial |
$48,051.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46,355.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$41,720.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16,959.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$49,747.47
|
| Rate for Payer: Ohio Health Group HMO |
$42,398.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45,224.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49,182.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39,006.54
|
| Rate for Payer: PHCS Commercial |
$54,269.97
|
| Rate for Payer: United Healthcare All Payer |
$49,747.47
|
|
|
SKYRIZI 1mg(600mg SDV)
|
Facility
|
OP
|
$56,531.22
|
|
|
Service Code
|
HCPCS J2327
|
| Hospital Charge Code |
25004311
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$54,269.97 |
| Rate for Payer: Aetna Commercial |
$43,529.04
|
| Rate for Payer: Anthem Medicaid |
$19,441.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$44,094.35
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$20.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.03
|
| Rate for Payer: Cash Price |
$28,265.61
|
| Rate for Payer: Cash Price |
$28,265.61
|
| Rate for Payer: Cigna Commercial |
$46,920.91
|
| Rate for Payer: First Health Commercial |
$53,704.66
|
| Rate for Payer: Humana Commercial |
$48,051.54
|
| Rate for Payer: Humana KY Medicaid |
$19,441.09
|
| Rate for Payer: Humana Medicare Advantage |
$14.84
|
| Rate for Payer: Kentucky WC Medicaid |
$19,638.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46,355.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$41,720.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$19,831.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$49,747.47
|
| Rate for Payer: Ohio Health Group HMO |
$42,398.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$45,224.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49,182.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39,006.54
|
| Rate for Payer: PHCS Commercial |
$54,269.97
|
| Rate for Payer: United Healthcare All Payer |
$49,747.47
|
|
|
SLEDGEHAMMER
|
Facility
|
OP
|
$95.00
|
|
| Hospital Charge Code |
22200123
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Anthem Medicaid |
$32.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.10
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: First Health Commercial |
$90.25
|
| Rate for Payer: Humana Commercial |
$80.75
|
| Rate for Payer: Humana KY Medicaid |
$32.67
|
| Rate for Payer: Kentucky WC Medicaid |
$33.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$33.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.60
|
| Rate for Payer: Ohio Health Group HMO |
$71.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.55
|
| Rate for Payer: PHCS Commercial |
$91.20
|
| Rate for Payer: United Healthcare All Payer |
$83.60
|
|
|
SLEDGEHAMMER
|
Professional
|
Both
|
$95.00
|
|
| Hospital Charge Code |
22200123
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$66.50 |
| 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
|
|
|
SLEDGEHAMMER
|
Facility
|
IP
|
$95.00
|
|
| Hospital Charge Code |
22200123
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$91.20 |
| Rate for Payer: Aetna Commercial |
$73.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.10
|
| Rate for Payer: Cash Price |
$47.50
|
| Rate for Payer: Cigna Commercial |
$78.85
|
| Rate for Payer: First Health Commercial |
$90.25
|
| Rate for Payer: Humana Commercial |
$80.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$77.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$83.60
|
| Rate for Payer: Ohio Health Group HMO |
$71.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$82.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$65.55
|
| Rate for Payer: PHCS Commercial |
$91.20
|
| Rate for Payer: United Healthcare All Payer |
$83.60
|
|
|
SLEEP LATENCY
|
Facility
|
OP
|
$3,460.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$490.26 |
| Max. Negotiated Rate |
$3,321.60 |
| Rate for Payer: Aetna Commercial |
$2,664.20
|
| Rate for Payer: Anthem Medicaid |
$1,189.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,698.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$1,730.00
|
| Rate for Payer: Cash Price |
$1,730.00
|
| Rate for Payer: Cigna Commercial |
$2,871.80
|
| Rate for Payer: First Health Commercial |
$3,287.00
|
| Rate for Payer: Humana Commercial |
$2,941.00
|
| Rate for Payer: Humana KY Medicaid |
$1,189.89
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$1,202.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,837.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,553.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,213.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,044.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,595.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,768.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,010.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,387.40
|
| Rate for Payer: PHCS Commercial |
$3,321.60
|
| Rate for Payer: United Healthcare All Payer |
$3,044.80
|
|
|
SLEEP LATENCY
|
Professional
|
Both
|
$3,460.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$73.98 |
| Max. Negotiated Rate |
$2,076.00 |
| Rate for Payer: Aetna Commercial |
$641.16
|
| Rate for Payer: Ambetter Exchange |
$391.92
|
| Rate for Payer: Anthem Medicaid |
$213.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$391.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$391.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$470.30
|
| Rate for Payer: Cash Price |
$1,730.00
|
| Rate for Payer: Cash Price |
$1,730.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$391.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.17
|
| Rate for Payer: Molina Healthcare Passport |
$213.89
|
| Rate for Payer: Multiplan PHCS |
$2,076.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$509.50
|
| Rate for Payer: UHCCP Medicaid |
$1,211.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.03
|
| Rate for Payer: Wellcare Medicare Advantage |
$391.92
|
|
