|
T4 (THYROXINE) TOTAL ONLY S
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 84436
|
| Hospital Charge Code |
30000526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$6.87
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.87
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$6.87
|
| Rate for Payer: Humana Medicare Advantage |
$6.87
|
| Rate for Payer: Kentucky WC Medicaid |
$6.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
T4 (THYROXINE) TOTAL ONLY S
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 84436
|
| Hospital Charge Code |
30000526
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
TABLET LANOXIN (DIG .13MG/1TAB
|
Facility
|
IP
|
$4.50
|
|
|
Service Code
|
NDC 143124001
|
| Hospital Charge Code |
25001480
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| 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 |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| 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 |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| 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 |
$1.35 |
| 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 |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| 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 |
$3.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$3.96
|
|
|
TABLET LANOXIN (DIG .25MG/1TAB
|
Facility
|
OP
|
$9.16
|
|
|
Service Code
|
NDC 60687055101
|
| Hospital Charge Code |
25001481
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| 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 |
$7.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.32
|
| Rate for Payer: PHCS Commercial |
$8.79
|
| Rate for Payer: United Healthcare All Payer |
$8.06
|
|
|
TABLET LANOXIN (DIG .25MG/1TAB
|
Facility
|
IP
|
$9.16
|
|
|
Service Code
|
NDC 60687055101
|
| Hospital Charge Code |
25001481
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.75 |
| 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 |
$7.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.32
|
| Rate for Payer: PHCS Commercial |
$8.79
|
| Rate for Payer: United Healthcare All Payer |
$8.06
|
|
|
TACHEOSTOMA REVISION
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 31613
|
| Hospital Charge Code |
41000033
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
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 |
$674.21 |
| Rate for Payer: Aetna Commercial |
$674.21
|
| Rate for Payer: Ambetter Exchange |
$390.84
|
| Rate for Payer: Anthem Medicaid |
$190.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$390.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$390.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.01
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$390.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.84
|
| 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 |
$508.09
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$390.84
|
|
|
TACHEOSTOMA REVISION
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 31613
|
| Hospital Charge Code |
41000033
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$257.93 |
| Max. Negotiated Rate |
$4,195.14 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,996.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,195.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,045.32
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.93
|
| Rate for Payer: Humana Medicare Advantage |
$2,996.53
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,595.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
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 |
$674.21 |
| Rate for Payer: Aetna Commercial |
$674.21
|
| Rate for Payer: Ambetter Exchange |
$390.84
|
| Rate for Payer: Anthem Medicaid |
$190.50
|
| Rate for Payer: Buckeye Individual/Medicaid |
$390.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$390.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$469.01
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$390.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.84
|
| 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 |
$508.09
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$192.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$390.84
|
|
|
TAH W/BURCH
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 58152
|
| Hospital Charge Code |
76102211
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| 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 |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| 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 |
$840.00 |
| 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 |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| 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 |
$1,899.32 |
| Rate for Payer: Aetna Commercial |
$1,899.32
|
| Rate for Payer: Ambetter Exchange |
$1,173.28
|
| Rate for Payer: Anthem Medicaid |
$798.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,173.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,173.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,407.94
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,173.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.28
|
| 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 |
$1,525.26
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$806.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,173.28
|
|
|
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 |
$1,899.32 |
| Rate for Payer: Aetna Commercial |
$1,899.32
|
| Rate for Payer: Ambetter Exchange |
$1,173.28
|
| Rate for Payer: Anthem Medicaid |
$798.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,173.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,173.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,407.94
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,173.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,173.28
|
| 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 |
$1,525.26
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$806.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,173.28
|
|
|
TAKE CONTROL
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
22200121
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna Commercial |
$23.10
|
| Rate for Payer: Anthem Medicaid |
$10.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$24.90
|
| Rate for Payer: First Health Commercial |
$28.50
|
| Rate for Payer: Humana Commercial |
$25.50
|
| Rate for Payer: Humana KY Medicaid |
$10.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.40
|
| Rate for Payer: Ohio Health Group HMO |
$22.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.70
|
| Rate for Payer: PHCS Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Payer |
$26.40
|
|
|
TAKE CONTROL
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
22200121
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna Commercial |
$23.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23.40
|
| Rate for Payer: Cash Price |
$15.00
|
| Rate for Payer: Cigna Commercial |
$24.90
|
| Rate for Payer: First Health Commercial |
$28.50
|
| Rate for Payer: Humana Commercial |
$25.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$26.40
|
| Rate for Payer: Ohio Health Group HMO |
$22.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.70
|
| Rate for Payer: PHCS Commercial |
$28.80
|
| Rate for Payer: United Healthcare All Payer |
$26.40
|
|
|
TAKE CONTROL
|
Professional
|
Both
|
$30.00
|
|
| Hospital Charge Code |
22200121
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$10.50 |
| Max. Negotiated Rate |
$21.00 |
| 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
|
IP
|
$2,001.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$600.33 |
| Max. Negotiated Rate |
$1,921.06 |
| Rate for Payer: Aetna Commercial |
$1,540.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.86
|
| Rate for Payer: Cash Price |
$1,000.55
|
| Rate for Payer: Cigna Commercial |
$1,660.91
|
| Rate for Payer: First Health Commercial |
$1,901.05
|
| Rate for Payer: Humana Commercial |
$1,700.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.97
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.76
|
| Rate for Payer: PHCS Commercial |
$1,921.06
|
| Rate for Payer: United Healthcare All Payer |
$1,760.97
|
|
|
TAKERU OTW BALLOON 1.5*12
|
Facility
|
OP
|
$2,001.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$600.33 |
| Max. Negotiated Rate |
$1,921.06 |
| Rate for Payer: Aetna Commercial |
$1,540.85
|
| Rate for Payer: Anthem Medicaid |
$688.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.86
|
| Rate for Payer: Cash Price |
$1,000.55
|
| Rate for Payer: Cigna Commercial |
$1,660.91
|
| Rate for Payer: First Health Commercial |
$1,901.05
|
| Rate for Payer: Humana Commercial |
$1,700.93
|
| Rate for Payer: Humana KY Medicaid |
$688.18
|
| Rate for Payer: Kentucky WC Medicaid |
$695.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.97
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.76
|
| Rate for Payer: PHCS Commercial |
$1,921.06
|
| Rate for Payer: United Healthcare All Payer |
$1,760.97
|
|
|
TAKERU OTW BALLOON 1.5*15
|
Facility
|
OP
|
$2,001.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$600.33 |
| Max. Negotiated Rate |
$1,921.06 |
| Rate for Payer: Aetna Commercial |
$1,540.85
|
| Rate for Payer: Anthem Medicaid |
$688.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.86
|
| Rate for Payer: Cash Price |
$1,000.55
|
| Rate for Payer: Cigna Commercial |
$1,660.91
|
| Rate for Payer: First Health Commercial |
$1,901.05
|
| Rate for Payer: Humana Commercial |
$1,700.93
|
| Rate for Payer: Humana KY Medicaid |
$688.18
|
| Rate for Payer: Kentucky WC Medicaid |
$695.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.97
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.76
|
| Rate for Payer: PHCS Commercial |
$1,921.06
|
| Rate for Payer: United Healthcare All Payer |
$1,760.97
|
|
|
TAKERU OTW BALLOON 1.5*15
|
Facility
|
IP
|
$2,001.10
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$600.33 |
| Max. Negotiated Rate |
$1,921.06 |
| Rate for Payer: Aetna Commercial |
$1,540.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.86
|
| Rate for Payer: Cash Price |
$1,000.55
|
| Rate for Payer: Cigna Commercial |
$1,660.91
|
| Rate for Payer: First Health Commercial |
$1,901.05
|
| Rate for Payer: Humana Commercial |
$1,700.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.97
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.76
|
| Rate for Payer: PHCS Commercial |
$1,921.06
|
| Rate for Payer: United Healthcare All Payer |
$1,760.97
|
|
|
TAKERU OTW BALLOON 1.5*6
|
Facility
|
IP
|
$1,721.80
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.54 |
| Max. Negotiated Rate |
$1,652.93 |
| Rate for Payer: Aetna Commercial |
$1,325.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,343.00
|
| Rate for Payer: Cash Price |
$860.90
|
| Rate for Payer: Cigna Commercial |
$1,429.09
|
| Rate for Payer: First Health Commercial |
$1,635.71
|
| Rate for Payer: Humana Commercial |
$1,463.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,411.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,270.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$516.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,515.18
|
| Rate for Payer: Ohio Health Group HMO |
$1,291.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,188.04
|
| Rate for Payer: PHCS Commercial |
$1,652.93
|
| Rate for Payer: United Healthcare All Payer |
$1,515.18
|
|
|
TAKERU OTW BALLOON 1.5*6
|
Facility
|
OP
|
$1,721.80
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$516.54 |
| Max. Negotiated Rate |
$1,652.93 |
| Rate for Payer: Aetna Commercial |
$1,325.79
|
| Rate for Payer: Anthem Medicaid |
$592.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,343.00
|
| Rate for Payer: Cash Price |
$860.90
|
| Rate for Payer: Cigna Commercial |
$1,429.09
|
| Rate for Payer: First Health Commercial |
$1,635.71
|
| Rate for Payer: Humana Commercial |
$1,463.53
|
| Rate for Payer: Humana KY Medicaid |
$592.13
|
| Rate for Payer: Kentucky WC Medicaid |
$598.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,411.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,270.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$516.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$604.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,515.18
|
| Rate for Payer: Ohio Health Group HMO |
$1,291.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,377.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,188.04
|
| Rate for Payer: PHCS Commercial |
$1,652.93
|
| Rate for Payer: United Healthcare All Payer |
$1,515.18
|
|
|
TAKERU OTW BALLOON 2*12
|
Facility
|
IP
|
$1,737.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
TAKERU OTW BALLOON 2*12
|
Facility
|
OP
|
$1,737.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem Medicaid |
$597.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Humana KY Medicaid |
$597.35
|
| Rate for Payer: Kentucky WC Medicaid |
$603.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
