|
T2 SCREW FTHRD LOCKING 5*32.5
|
Facility
|
OP
|
$1,832.09
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$238.17 |
| Max. Negotiated Rate |
$1,758.81 |
| Rate for Payer: Aetna Commercial |
$1,410.71
|
| Rate for Payer: Anthem Medicaid |
$630.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,429.03
|
| Rate for Payer: Cash Price |
$916.04
|
| Rate for Payer: Cigna Commercial |
$1,520.63
|
| Rate for Payer: First Health Commercial |
$1,740.49
|
| Rate for Payer: Humana Commercial |
$1,557.28
|
| Rate for Payer: Humana KY Medicaid |
$630.06
|
| Rate for Payer: Kentucky WC Medicaid |
$636.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,502.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,352.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$549.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$642.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,612.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,374.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$366.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$238.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$567.95
|
| Rate for Payer: PHCS Commercial |
$1,758.81
|
| Rate for Payer: United Healthcare All Payer |
$1,612.24
|
|
|
T3 TOTAL
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
HCPCS 84480
|
| Hospital Charge Code |
30000542
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$185.28 |
| Rate for Payer: Aetna Commercial |
$148.61
|
| Rate for Payer: Anthem Medicaid |
$66.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$14.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$19.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.18
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$160.19
|
| Rate for Payer: First Health Commercial |
$183.35
|
| Rate for Payer: Humana Commercial |
$164.05
|
| Rate for Payer: Humana KY Medicaid |
$66.37
|
| Rate for Payer: Humana Medicare Advantage |
$14.18
|
| Rate for Payer: Kentucky WC Medicaid |
$67.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$158.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$142.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.84
|
| Rate for Payer: Ohio Health Group HMO |
$144.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.83
|
| Rate for Payer: PHCS Commercial |
$185.28
|
| Rate for Payer: United Healthcare All Payer |
$169.84
|
|
|
T3 TOTAL
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
HCPCS 84480
|
| Hospital Charge Code |
30000542
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.09 |
| Max. Negotiated Rate |
$185.28 |
| Rate for Payer: Aetna Commercial |
$148.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$154.98
|
| Rate for Payer: Cash Price |
$96.50
|
| Rate for Payer: Cigna Commercial |
$160.19
|
| Rate for Payer: First Health Commercial |
$183.35
|
| Rate for Payer: Humana Commercial |
$164.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$158.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$142.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$169.84
|
| Rate for Payer: Ohio Health Group HMO |
$144.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.83
|
| Rate for Payer: PHCS Commercial |
$185.28
|
| Rate for Payer: United Healthcare All Payer |
$169.84
|
|
|
T4 (THYROXINE) TOTAL ONLY S
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS 84436
|
| Hospital Charge Code |
30000526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.87
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Humana Medicare Advantage |
$6.87
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
T4 (THYROXINE) TOTAL ONLY S
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 84436
|
| Hospital Charge Code |
30000526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.15
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.96
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
TABLET LANOXIN (DIG .13MG/1TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 143124001
|
| Hospital Charge Code |
25001480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TABLET LANOXIN (DIG .13MG/1TAB
|
Facility
|
OP
|
$4.50
|
|
|
Service Code
|
NDC 143124001
|
| Hospital Charge Code |
25001480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.32 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.96
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TABLET LANOXIN (DIG .25MG/1TAB
|
Facility
|
IP
|
$9.16
|
|
|
Service Code
|
NDC 60687055101
|
| Hospital Charge Code |
25001481
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$7.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: First Health Commercial |
$8.70
|
| Rate for Payer: Humana Commercial |
$7.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.06
|
| Rate for Payer: Ohio Health Group HMO |
$6.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.84
|
| Rate for Payer: PHCS Commercial |
$8.79
|
| Rate for Payer: United Healthcare All Payer |
$8.06
|
|
|
TABLET LANOXIN (DIG .25MG/1TAB
|
Facility
|
OP
|
$9.16
|
|
|
Service Code
|
NDC 60687055101
|
| Hospital Charge Code |
25001481
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.19 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$7.05
|
| Rate for Payer: Anthem Medicaid |
$3.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Cash Price |
$4.58
|
| Rate for Payer: Cigna Commercial |
$7.60
|
| Rate for Payer: First Health Commercial |
$8.70
|
| Rate for Payer: Humana Commercial |
$7.79
|
| Rate for Payer: Humana KY Medicaid |
$3.15
|
| Rate for Payer: Kentucky WC Medicaid |
$3.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.06
|
| Rate for Payer: Ohio Health Group HMO |
$6.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.84
|
| Rate for Payer: PHCS Commercial |
$8.79
|
| Rate for Payer: United Healthcare All Payer |
$8.06
|
|
|
TACHEOSTOMA REVISION
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 31613
|
| Hospital Charge Code |
41000033
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$190.50 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$674.21
|
| Rate for Payer: Anthem Medicaid |
$190.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$612.54
|
| Rate for Payer: Healthspan PPO |
$526.41
|
| Rate for Payer: Humana Medicaid |
$190.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$568.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$194.31
|
| Rate for Payer: Molina Healthcare Passport |
$190.50
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.40
|
|
|
TACHEOSTOMA REVISION(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 31613
|
| Hospital Charge Code |
410P0033
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$190.50 |
| Max. Negotiated Rate |
$750.00 |
| Rate for Payer: Aetna Commercial |
$674.21
|
| Rate for Payer: Anthem Medicaid |
$190.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$750.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$612.54
|
| Rate for Payer: Healthspan PPO |
$526.41
|
| Rate for Payer: Humana Medicaid |
$190.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$568.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$194.31
|
| Rate for Payer: Molina Healthcare Passport |
$190.50
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$525.00
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.40
|
|
|
TAH W/BURCH
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58152
|
| Hospital Charge Code |
76102211
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
TAH W/BURCH
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58152
|
| Hospital Charge Code |
76102211
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$364.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$868.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
TAH W/BURCH
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58152
|
| Hospital Charge Code |
76102211
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$798.27 |
| Max. Negotiated Rate |
$2,800.00 |
| Rate for Payer: Aetna Commercial |
$1,899.32
|
| Rate for Payer: Anthem Medicaid |
$798.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,800.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,860.94
|
| Rate for Payer: Healthspan PPO |
$1,839.03
|
| Rate for Payer: Humana Medicaid |
$798.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,624.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$814.24
|
| Rate for Payer: Molina Healthcare Passport |
$798.27
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,960.00
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$806.25
|
|
|
TAH W/BURCH(P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58152
|
| Hospital Charge Code |
761P2211
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$798.27 |
| Max. Negotiated Rate |
$2,800.00 |
| Rate for Payer: Aetna Commercial |
$1,899.32
|
| Rate for Payer: Anthem Medicaid |
$798.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,800.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,860.94
|
| Rate for Payer: Healthspan PPO |
$1,839.03
|
| Rate for Payer: Humana Medicaid |
$798.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,624.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$814.24
|
| Rate for Payer: Molina Healthcare Passport |
$798.27
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,960.00
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$806.25
|
|
|
TAKE CONTROL
|
Professional
|
Both
|
$30.00
|
|
| Hospital Charge Code |
22200121
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$30.00
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Multiplan PHCS |
$18.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.00
|
| Rate for Payer: UHCCP Medicaid |
$10.50
|
|
|
TAKERU OTW BALLOON 1.5*12
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU OTW BALLOON 1.5*12
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU OTW BALLOON 1.5*15
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU OTW BALLOON 1.5*15
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU OTW BALLOON 1.5*6
|
Facility
|
IP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU OTW BALLOON 1.5*6
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
|
TAKERU OTW BALLOON 2*12
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU OTW BALLOON 2*12
|
Facility
|
OP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem Medicaid |
$602.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Humana KY Medicaid |
$602.68
|
| Rate for Payer: Kentucky WC Medicaid |
$608.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
|
TAKERU OTW BALLOON 2*15
|
Facility
|
OP
|
$1,738.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$226.00 |
| Max. Negotiated Rate |
$1,668.96 |
| Rate for Payer: Aetna Commercial |
$1,338.64
|
| Rate for Payer: Anthem Medicaid |
$597.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,356.03
|
| Rate for Payer: Cash Price |
$869.25
|
| Rate for Payer: Cigna Commercial |
$1,442.96
|
| Rate for Payer: First Health Commercial |
$1,651.58
|
| Rate for Payer: Humana Commercial |
$1,477.72
|
| Rate for Payer: Humana KY Medicaid |
$597.87
|
| Rate for Payer: Kentucky WC Medicaid |
$603.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,425.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,283.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,529.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,303.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$347.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$226.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$538.94
|
| Rate for Payer: PHCS Commercial |
$1,668.96
|
| Rate for Payer: United Healthcare All Payer |
$1,529.88
|
|
