|
TRTNUM RVSN ACTBLR SHLL 60F
|
Facility
|
OP
|
$18,512.91
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,553.87 |
| Max. Negotiated Rate |
$17,772.39 |
| Rate for Payer: Aetna Commercial |
$14,254.94
|
| Rate for Payer: Anthem Medicaid |
$6,366.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,440.07
|
| Rate for Payer: Cash Price |
$9,256.46
|
| Rate for Payer: Cigna Commercial |
$15,365.72
|
| Rate for Payer: First Health Commercial |
$17,587.26
|
| Rate for Payer: Humana Commercial |
$15,735.97
|
| Rate for Payer: Humana KY Medicaid |
$6,366.59
|
| Rate for Payer: Kentucky WC Medicaid |
$6,431.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,180.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,662.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,553.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,494.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,291.36
|
| Rate for Payer: Ohio Health Group HMO |
$13,884.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,810.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,106.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,773.91
|
| Rate for Payer: PHCS Commercial |
$17,772.39
|
| Rate for Payer: United Healthcare All Payer |
$16,291.36
|
|
|
TRTNUM RVSN ACTBLR SHLL 60F
|
Facility
|
IP
|
$18,512.91
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,553.87 |
| Max. Negotiated Rate |
$17,772.39 |
| Rate for Payer: Aetna Commercial |
$14,254.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,440.07
|
| Rate for Payer: Cash Price |
$9,256.46
|
| Rate for Payer: Cigna Commercial |
$15,365.72
|
| Rate for Payer: First Health Commercial |
$17,587.26
|
| Rate for Payer: Humana Commercial |
$15,735.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,180.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,662.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,553.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,291.36
|
| Rate for Payer: Ohio Health Group HMO |
$13,884.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,810.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,106.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,773.91
|
| Rate for Payer: PHCS Commercial |
$17,772.39
|
| Rate for Payer: United Healthcare All Payer |
$16,291.36
|
|
|
TRTNUM RVSN ACTBLR SHLL 62G
|
Facility
|
IP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 62G
|
Facility
|
OP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem Medicaid |
$5,747.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Humana KY Medicaid |
$5,747.81
|
| Rate for Payer: Kentucky WC Medicaid |
$5,806.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,863.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 66G
|
Facility
|
IP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 66G
|
Facility
|
OP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem Medicaid |
$5,747.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Humana KY Medicaid |
$5,747.81
|
| Rate for Payer: Kentucky WC Medicaid |
$5,806.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,863.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 68G
|
Facility
|
OP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem Medicaid |
$5,747.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Humana KY Medicaid |
$5,747.81
|
| Rate for Payer: Kentucky WC Medicaid |
$5,806.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,863.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 68G
|
Facility
|
IP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 721
|
Facility
|
OP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem Medicaid |
$5,747.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Humana KY Medicaid |
$5,747.81
|
| Rate for Payer: Kentucky WC Medicaid |
$5,806.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,863.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRTNUM RVSN ACTBLR SHLL 721
|
Facility
|
IP
|
$16,713.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,014.08 |
| Max. Negotiated Rate |
$16,045.06 |
| Rate for Payer: Aetna Commercial |
$12,869.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,036.61
|
| Rate for Payer: Cash Price |
$8,356.80
|
| Rate for Payer: Cigna Commercial |
$13,872.29
|
| Rate for Payer: First Health Commercial |
$15,877.92
|
| Rate for Payer: Humana Commercial |
$14,206.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,705.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,334.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,014.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,707.97
|
| Rate for Payer: Ohio Health Group HMO |
$12,535.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,370.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,540.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,532.38
|
| Rate for Payer: PHCS Commercial |
$16,045.06
|
| Rate for Payer: United Healthcare All Payer |
$14,707.97
|
|
|
TRUEPATH DEVICE
|
Facility
|
OP
|
$10,008.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,002.40 |
| Max. Negotiated Rate |
$9,607.68 |
| Rate for Payer: Aetna Commercial |
$7,706.16
|
| Rate for Payer: Anthem Medicaid |
$3,441.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,806.24
|
| Rate for Payer: Cash Price |
$5,004.00
|
| Rate for Payer: Cigna Commercial |
$8,306.64
|
| Rate for Payer: First Health Commercial |
$9,507.60
|
| Rate for Payer: Humana Commercial |
$8,506.80
|
| Rate for Payer: Humana KY Medicaid |
$3,441.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,476.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,206.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,385.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,002.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,510.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,807.04
|
| Rate for Payer: Ohio Health Group HMO |
$7,506.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,006.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,706.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,905.52
|
| Rate for Payer: PHCS Commercial |
$9,607.68
|
| Rate for Payer: United Healthcare All Payer |
$8,807.04
|
|
|
TRUEPATH DEVICE
|
Facility
|
IP
|
$10,008.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,002.40 |
| Max. Negotiated Rate |
$9,607.68 |
| Rate for Payer: Aetna Commercial |
$7,706.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,806.24
|
| Rate for Payer: Cash Price |
$5,004.00
|
| Rate for Payer: Cigna Commercial |
$8,306.64
|
| Rate for Payer: First Health Commercial |
$9,507.60
|
| Rate for Payer: Humana Commercial |
$8,506.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,206.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,385.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,002.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,807.04
|
| Rate for Payer: Ohio Health Group HMO |
$7,506.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,006.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,706.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,905.52
|
| Rate for Payer: PHCS Commercial |
$9,607.68
|
| Rate for Payer: United Healthcare All Payer |
$8,807.04
|
|
|
TRUESPAN MEN RPR W/PEEK IMP 0^
|
Facility
|
IP
|
$4,988.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.62 |
| Max. Negotiated Rate |
$4,789.20 |
| Rate for Payer: Aetna Commercial |
$3,841.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,891.22
|
| Rate for Payer: Cash Price |
$2,494.38
|
| Rate for Payer: Cigna Commercial |
$4,140.66
|
| Rate for Payer: First Health Commercial |
$4,739.31
|
| Rate for Payer: Humana Commercial |
$4,240.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,090.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,681.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,496.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,390.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,741.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,991.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,340.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,442.24
|
| Rate for Payer: PHCS Commercial |
$4,789.20
|
| Rate for Payer: United Healthcare All Payer |
$4,390.10
|
|
|
TRUESPAN MEN RPR W/PEEK IMP 0^
|
Facility
|
OP
|
$4,988.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,496.62 |
| Max. Negotiated Rate |
$4,789.20 |
| Rate for Payer: Aetna Commercial |
$3,841.34
|
| Rate for Payer: Anthem Medicaid |
$1,715.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,891.22
|
| Rate for Payer: Cash Price |
$2,494.38
|
| Rate for Payer: Cigna Commercial |
$4,140.66
|
| Rate for Payer: First Health Commercial |
$4,739.31
|
| Rate for Payer: Humana Commercial |
$4,240.44
|
| Rate for Payer: Humana KY Medicaid |
$1,715.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1,733.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,090.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,681.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,496.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,750.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,390.10
|
| Rate for Payer: Ohio Health Group HMO |
$3,741.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,991.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,340.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,442.24
|
| Rate for Payer: PHCS Commercial |
$4,789.20
|
| Rate for Payer: United Healthcare All Payer |
$4,390.10
|
|
|
TRUESPAN MEN RPR W/PEEK IMP 12
|
Facility
|
IP
|
$5,611.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.38 |
| Max. Negotiated Rate |
$5,386.80 |
| Rate for Payer: Aetna Commercial |
$4,320.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,376.77
|
| Rate for Payer: Cash Price |
$2,805.62
|
| Rate for Payer: Cigna Commercial |
$4,657.34
|
| Rate for Payer: First Health Commercial |
$5,330.69
|
| Rate for Payer: Humana Commercial |
$4,769.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,601.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,141.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,683.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,937.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,208.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,489.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,881.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,871.76
|
| Rate for Payer: PHCS Commercial |
$5,386.80
|
| Rate for Payer: United Healthcare All Payer |
$4,937.90
|
|
|
TRUESPAN MEN RPR W/PEEK IMP 12
|
Facility
|
OP
|
$5,611.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,683.38 |
| Max. Negotiated Rate |
$5,386.80 |
| Rate for Payer: Aetna Commercial |
$4,320.66
|
| Rate for Payer: Anthem Medicaid |
$1,929.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,376.77
|
| Rate for Payer: Cash Price |
$2,805.62
|
| Rate for Payer: Cigna Commercial |
$4,657.34
|
| Rate for Payer: First Health Commercial |
$5,330.69
|
| Rate for Payer: Humana Commercial |
$4,769.56
|
| Rate for Payer: Humana KY Medicaid |
$1,929.71
|
| Rate for Payer: Kentucky WC Medicaid |
$1,949.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,601.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,141.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,683.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,968.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,937.90
|
| Rate for Payer: Ohio Health Group HMO |
$4,208.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,489.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,881.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,871.76
|
| Rate for Payer: PHCS Commercial |
$5,386.80
|
| Rate for Payer: United Healthcare All Payer |
$4,937.90
|
|
|
TRUESPAN MEN RPR W/PEEK IMP 24
|
Facility
|
IP
|
$5,108.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,532.62 |
| Max. Negotiated Rate |
$4,904.40 |
| Rate for Payer: Aetna Commercial |
$3,933.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,984.82
|
| Rate for Payer: Cash Price |
$2,554.38
|
| Rate for Payer: Cigna Commercial |
$4,240.26
|
| Rate for Payer: First Health Commercial |
$4,853.31
|
| Rate for Payer: Humana Commercial |
$4,342.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,189.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,770.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,532.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,495.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,831.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,087.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,444.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,525.04
|
| Rate for Payer: PHCS Commercial |
$4,904.40
|
| Rate for Payer: United Healthcare All Payer |
$4,495.70
|
|
|
TRUESPAN MEN RPR W/PEEK IMP 24
|
Facility
|
OP
|
$5,108.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,532.62 |
| Max. Negotiated Rate |
$4,904.40 |
| Rate for Payer: Aetna Commercial |
$3,933.74
|
| Rate for Payer: Anthem Medicaid |
$1,756.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,984.82
|
| Rate for Payer: Cash Price |
$2,554.38
|
| Rate for Payer: Cigna Commercial |
$4,240.26
|
| Rate for Payer: First Health Commercial |
$4,853.31
|
| Rate for Payer: Humana Commercial |
$4,342.44
|
| Rate for Payer: Humana KY Medicaid |
$1,756.90
|
| Rate for Payer: Kentucky WC Medicaid |
$1,774.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,189.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,770.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,532.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,792.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,495.70
|
| Rate for Payer: Ohio Health Group HMO |
$3,831.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,087.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,444.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,525.04
|
| Rate for Payer: PHCS Commercial |
$4,904.40
|
| Rate for Payer: United Healthcare All Payer |
$4,495.70
|
|
|
TRUNION KIT FOR UNIV II
|
Facility
|
IP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
TRUNION KIT FOR UNIV II
|
Facility
|
OP
|
$3,125.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$937.50 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$2,406.25
|
| Rate for Payer: Anthem Medicaid |
$1,074.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,437.50
|
| Rate for Payer: Cash Price |
$1,562.50
|
| Rate for Payer: Cigna Commercial |
$2,593.75
|
| Rate for Payer: First Health Commercial |
$2,968.75
|
| Rate for Payer: Humana Commercial |
$2,656.25
|
| Rate for Payer: Humana KY Medicaid |
$1,074.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,085.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,562.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,306.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$937.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,096.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,750.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,343.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,718.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,156.25
|
| Rate for Payer: PHCS Commercial |
$3,000.00
|
| Rate for Payer: United Healthcare All Payer |
$2,750.00
|
|
|
TRUSOPT 2% EYE EQUIV DROPS
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 42571014126
|
| Hospital Charge Code |
25001605
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna Commercial |
$0.72
|
| Rate for Payer: Anthem Medicaid |
$0.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.73
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna Commercial |
$0.77
|
| Rate for Payer: First Health Commercial |
$0.88
|
| Rate for Payer: Humana Commercial |
$0.79
|
| Rate for Payer: Humana KY Medicaid |
$0.32
|
| Rate for Payer: Kentucky WC Medicaid |
$0.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.82
|
| Rate for Payer: Ohio Health Group HMO |
$0.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.64
|
| Rate for Payer: PHCS Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Payer |
$0.82
|
|
|
TRUSOPT 2% EYE EQUIV DROPS
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 42571014126
|
| Hospital Charge Code |
25001605
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.89 |
| Rate for Payer: Aetna Commercial |
$0.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.73
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna Commercial |
$0.77
|
| Rate for Payer: First Health Commercial |
$0.88
|
| Rate for Payer: Humana Commercial |
$0.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.82
|
| Rate for Payer: Ohio Health Group HMO |
$0.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.64
|
| Rate for Payer: PHCS Commercial |
$0.89
|
| Rate for Payer: United Healthcare All Payer |
$0.82
|
|
|
TRUVADA 200/300MG TABLET
|
Facility
|
OP
|
$133.41
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
25001606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.02 |
| Max. Negotiated Rate |
$128.07 |
| Rate for Payer: Aetna Commercial |
$102.73
|
| Rate for Payer: Anthem Medicaid |
$45.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.06
|
| Rate for Payer: Cash Price |
$66.70
|
| Rate for Payer: Cigna Commercial |
$110.73
|
| Rate for Payer: First Health Commercial |
$126.74
|
| Rate for Payer: Humana Commercial |
$113.40
|
| Rate for Payer: Humana KY Medicaid |
$45.88
|
| Rate for Payer: Kentucky WC Medicaid |
$46.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$46.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.40
|
| Rate for Payer: Ohio Health Group HMO |
$100.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.05
|
| Rate for Payer: PHCS Commercial |
$128.07
|
| Rate for Payer: United Healthcare All Payer |
$117.40
|
|
|
TRUVADA 200/300MG TABLET
|
Facility
|
IP
|
$133.41
|
|
|
Service Code
|
NDC 61958070101
|
| Hospital Charge Code |
25001606
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.02 |
| Max. Negotiated Rate |
$128.07 |
| Rate for Payer: Aetna Commercial |
$102.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$104.06
|
| Rate for Payer: Cash Price |
$66.70
|
| Rate for Payer: Cigna Commercial |
$110.73
|
| Rate for Payer: First Health Commercial |
$126.74
|
| Rate for Payer: Humana Commercial |
$113.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$109.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$98.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$117.40
|
| Rate for Payer: Ohio Health Group HMO |
$100.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$116.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.05
|
| Rate for Payer: PHCS Commercial |
$128.07
|
| Rate for Payer: United Healthcare All Payer |
$117.40
|
|
|
TRUXIMA 10mg (100mg Vial)
|
Facility
|
OP
|
$4,608.25
|
|
|
Service Code
|
HCPCS Q5115
|
| Hospital Charge Code |
25003880
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.18 |
| Max. Negotiated Rate |
$4,423.92 |
| Rate for Payer: Aetna Commercial |
$3,548.35
|
| Rate for Payer: Anthem Medicaid |
$1,584.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$31.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,594.43
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$43.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.09
|
| Rate for Payer: Cash Price |
$2,304.12
|
| Rate for Payer: Cash Price |
$2,304.12
|
| Rate for Payer: Cigna Commercial |
$3,824.85
|
| Rate for Payer: First Health Commercial |
$4,377.84
|
| Rate for Payer: Humana Commercial |
$3,917.01
|
| Rate for Payer: Humana KY Medicaid |
$1,584.78
|
| Rate for Payer: Humana Medicare Advantage |
$31.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,600.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,778.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,400.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,616.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,055.26
|
| Rate for Payer: Ohio Health Group HMO |
$3,456.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,686.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,009.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,179.69
|
| Rate for Payer: PHCS Commercial |
$4,423.92
|
| Rate for Payer: United Healthcare All Payer |
$4,055.26
|
|
