|
SUMMIT CEM STEM STD OFFST SZ 7
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 8
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 8
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUNSCREEN/PRIMER SPF30 30ML
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
22200150
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCREEN/PRIMER SPF30 30ML
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
22200150
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCREEN/PRIMER SPF30 30ML
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200150
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 DP
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
22200360
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 DP
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
22200360
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 DP
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200360
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 L
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
22200358
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 L
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
22200358
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 L
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200358
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 M
|
Facility
|
IP
|
$65.00
|
|
| Hospital Charge Code |
22200359
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 M
|
Professional
|
Both
|
$65.00
|
|
| Hospital Charge Code |
22200359
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Multiplan PHCS |
$39.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.50
|
| Rate for Payer: UHCCP Medicaid |
$22.75
|
|
|
SUNSCRN+PWDR BD-SPCTM SPF40 M
|
Facility
|
OP
|
$65.00
|
|
| Hospital Charge Code |
22200359
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$22.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$50.70
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$22.35
|
| Rate for Payer: Kentucky WC Medicaid |
$22.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$22.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.85
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
IP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
25004016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$387.84 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,034.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.03
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
IP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
636T0120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$387.84 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,034.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.03
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Professional
|
Both
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
63600120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$775.67 |
| Rate for Payer: Aetna Commercial |
$105.65
|
| Rate for Payer: Ambetter Exchange |
$73.39
|
| Rate for Payer: Anthem Medicaid |
$130.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$73.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$73.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.07
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$130.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$107.80
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$73.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.11
|
| Rate for Payer: Molina Healthcare Passport |
$130.50
|
| Rate for Payer: Multiplan PHCS |
$775.67
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$95.41
|
| Rate for Payer: UHCCP Medicaid |
$452.48
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$131.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$73.39
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
IP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
63600120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$387.84 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,034.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.03
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
OP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
636T0120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$387.84 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem Medicaid |
$444.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Humana KY Medicaid |
$444.59
|
| Rate for Payer: Kentucky WC Medicaid |
$449.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,034.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.03
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
OP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
25004016
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$387.84 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem Medicaid |
$444.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Humana KY Medicaid |
$444.59
|
| Rate for Payer: Kentucky WC Medicaid |
$449.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,034.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.03
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPARTZFX 2.5ML SYR
|
Facility
|
OP
|
$1,292.79
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
63600120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$387.84 |
| Max. Negotiated Rate |
$1,241.08 |
| Rate for Payer: Aetna Commercial |
$995.45
|
| Rate for Payer: Anthem Medicaid |
$444.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,008.38
|
| Rate for Payer: Cash Price |
$646.40
|
| Rate for Payer: Cigna Commercial |
$1,073.02
|
| Rate for Payer: First Health Commercial |
$1,228.15
|
| Rate for Payer: Humana Commercial |
$1,098.87
|
| Rate for Payer: Humana KY Medicaid |
$444.59
|
| Rate for Payer: Kentucky WC Medicaid |
$449.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,060.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$954.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$387.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$453.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,137.66
|
| Rate for Payer: Ohio Health Group HMO |
$969.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,034.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,124.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$892.03
|
| Rate for Payer: PHCS Commercial |
$1,241.08
|
| Rate for Payer: United Healthcare All Payer |
$1,137.66
|
|
|
SUPERA PERIPH. STENT 5*100*120
|
Facility
|
OP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem Medicaid |
$1,751.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Humana KY Medicaid |
$1,751.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,769.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,786.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
SUPERA PERIPH. STENT 5*100*120
|
Facility
|
IP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
SUPERA PERIPH. STENT 5*120*120
|
Facility
|
IP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
