|
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 |
$1,542.59 |
| 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 |
$4,113.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,473.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,547.95
|
| 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
|
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 |
$1,031.79 |
| Rate for Payer: Aetna Commercial |
$1,031.79
|
| Rate for Payer: Ambetter Exchange |
$674.94
|
| 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 Individual/Medicaid |
$674.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$674.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$809.93
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$674.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$674.94
|
| 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 |
$877.42
|
| Rate for Payer: UHCCP Medicaid |
$384.26
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$383.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$674.94
|
|
|
SPORANOX 10MG/ML ORAL (10ML)
|
Facility
|
OP
|
$40.31
|
|
|
Service Code
|
NDC 50458029515
|
| Hospital Charge Code |
25001423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$38.70 |
| Rate for Payer: Aetna Commercial |
$31.04
|
| Rate for Payer: Anthem Medicaid |
$13.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.44
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Cigna Commercial |
$33.46
|
| Rate for Payer: First Health Commercial |
$38.29
|
| Rate for Payer: Humana Commercial |
$34.26
|
| Rate for Payer: Humana KY Medicaid |
$13.86
|
| Rate for Payer: Kentucky WC Medicaid |
$14.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.47
|
| Rate for Payer: Ohio Health Group HMO |
$30.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.81
|
| Rate for Payer: PHCS Commercial |
$38.70
|
| Rate for Payer: United Healthcare All Payer |
$35.47
|
|
|
SPORANOX 10MG/ML ORAL (10ML)
|
Facility
|
IP
|
$40.31
|
|
|
Service Code
|
NDC 50458029515
|
| Hospital Charge Code |
25001423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$38.70 |
| Rate for Payer: Aetna Commercial |
$31.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.44
|
| Rate for Payer: Cash Price |
$20.16
|
| Rate for Payer: Cigna Commercial |
$33.46
|
| Rate for Payer: First Health Commercial |
$38.29
|
| Rate for Payer: Humana Commercial |
$34.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.47
|
| Rate for Payer: Ohio Health Group HMO |
$30.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$27.81
|
| Rate for Payer: PHCS Commercial |
$38.70
|
| Rate for Payer: United Healthcare All Payer |
$35.47
|
|
|
SPORANOX (ITRACONAZ 100MG/1CAP
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 67877045430
|
| Hospital Charge Code |
25001422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| 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 |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| 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 |
$2.90 |
| 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 |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
SPORTS PHYSICAL
|
Facility
|
OP
|
$25.00
|
|
| Hospital Charge Code |
45000321
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$7.50 |
| 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 |
$8.69
|
| 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 |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| Rate for Payer: PHCS Commercial |
$24.00
|
| Rate for Payer: United Healthcare All Payer |
$22.00
|
|
|
SPORTS PHYSICAL
|
Facility
|
IP
|
$25.00
|
|
| Hospital Charge Code |
45000321
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$7.50 |
| 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 |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.25
|
| 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 |
$17.50 |
| 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 |
$17.50 |
| 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 |
$88.90 |
| 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 |
$140.00 |
| 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 |
$179.20 |
| 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
|
|
|
SPRINTER LEGEND OTW 1.25*10
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND OTW 1.25*10
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND OTW 1.25*15
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND OTW 1.25*15
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND OTW 1.25*20
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND OTW 1.25*20
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND RX 1.25*10
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND RX 1.25*10
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND RX 1.25*12
|
Facility
|
OP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem Medicaid |
$404.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Humana KY Medicaid |
$404.08
|
| Rate for Payer: Kentucky WC Medicaid |
$408.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$412.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SPRINTER LEGEND RX 1.25*12
|
Facility
|
IP
|
$1,175.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$352.50 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna Commercial |
$904.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$916.50
|
| Rate for Payer: Cash Price |
$587.50
|
| Rate for Payer: Cigna Commercial |
$975.25
|
| Rate for Payer: First Health Commercial |
$1,116.25
|
| Rate for Payer: Humana Commercial |
$998.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$963.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$867.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$352.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,034.00
|
| Rate for Payer: Ohio Health Group HMO |
$881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$940.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,022.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$810.75
|
| Rate for Payer: PHCS Commercial |
$1,128.00
|
| Rate for Payer: United Healthcare All Payer |
$1,034.00
|
|
|
SPRINTER LEGEND RX 1.25*15
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SPRINTER LEGEND RX 1.25*15
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
