|
CPLX RPR SC - EXT 1.1-2.5(T
|
Facility
|
OP
|
$1,355.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
761T0152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$176.15 |
| Max. Negotiated Rate |
$1,300.80 |
| Rate for Payer: Aetna Commercial |
$1,043.35
|
| Rate for Payer: Anthem Medicaid |
$465.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,056.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$677.50
|
| Rate for Payer: Cash Price |
$677.50
|
| Rate for Payer: Cigna Commercial |
$1,124.65
|
| Rate for Payer: First Health Commercial |
$1,287.25
|
| Rate for Payer: Humana Commercial |
$1,151.75
|
| Rate for Payer: Humana KY Medicaid |
$465.98
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$470.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,111.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$999.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$475.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,192.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,016.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$271.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.05
|
| Rate for Payer: PHCS Commercial |
$1,300.80
|
| Rate for Payer: United Healthcare All Payer |
$1,192.40
|
|
|
CPLX RPR SC - EXT 1.1-2.5(T
|
Facility
|
IP
|
$1,355.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
761T0152
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$176.15 |
| Max. Negotiated Rate |
$1,300.80 |
| Rate for Payer: Aetna Commercial |
$1,043.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,056.90
|
| Rate for Payer: Cash Price |
$677.50
|
| Rate for Payer: Cigna Commercial |
$1,124.65
|
| Rate for Payer: First Health Commercial |
$1,287.25
|
| Rate for Payer: Humana Commercial |
$1,151.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,111.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$999.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$406.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,192.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,016.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$271.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$176.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.05
|
| Rate for Payer: PHCS Commercial |
$1,300.80
|
| Rate for Payer: United Healthcare All Payer |
$1,192.40
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
OP
|
$1,351.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
76100153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.63 |
| Max. Negotiated Rate |
$1,296.96 |
| Rate for Payer: Aetna Commercial |
$1,040.27
|
| Rate for Payer: Anthem Medicaid |
$464.61
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,053.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$675.50
|
| Rate for Payer: Cash Price |
$675.50
|
| Rate for Payer: Cigna Commercial |
$1,121.33
|
| Rate for Payer: First Health Commercial |
$1,283.45
|
| Rate for Payer: Humana Commercial |
$1,148.35
|
| Rate for Payer: Humana KY Medicaid |
$464.61
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$469.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,107.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$997.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$473.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,188.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,013.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$270.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$175.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$418.81
|
| Rate for Payer: PHCS Commercial |
$1,296.96
|
| Rate for Payer: United Healthcare All Payer |
$1,188.88
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Professional
|
Both
|
$1,351.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
76100153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.78 |
| Max. Negotiated Rate |
$1,351.00 |
| Rate for Payer: Aetna Commercial |
$457.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$129.78
|
| Rate for Payer: Anthem Medicaid |
$169.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,351.00
|
| Rate for Payer: Cash Price |
$675.50
|
| Rate for Payer: Cash Price |
$675.50
|
| Rate for Payer: Cigna Commercial |
$538.97
|
| Rate for Payer: Healthspan PPO |
$483.39
|
| Rate for Payer: Humana Medicaid |
$169.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.53
|
| Rate for Payer: Molina Healthcare Passport |
$169.15
|
| Rate for Payer: Multiplan PHCS |
$810.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$945.70
|
| Rate for Payer: UHCCP Medicaid |
$136.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.84
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
OP
|
$801.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
45000070
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem Medicaid |
$275.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Humana KY Medicaid |
$275.46
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$278.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
IP
|
$801.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
45000070
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM
|
Facility
|
IP
|
$1,351.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
76100153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$175.63 |
| Max. Negotiated Rate |
$1,296.96 |
| Rate for Payer: Aetna Commercial |
$1,040.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,053.78
|
| Rate for Payer: Cash Price |
$675.50
|
| Rate for Payer: Cigna Commercial |
$1,121.33
|
| Rate for Payer: First Health Commercial |
$1,283.45
|
| Rate for Payer: Humana Commercial |
$1,148.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,107.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$997.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,188.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,013.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$270.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$175.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$418.81
|
| Rate for Payer: PHCS Commercial |
$1,296.96
|
| Rate for Payer: United Healthcare All Payer |
$1,188.88
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM(P
|
Professional
|
Both
|
$550.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
761P0153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$129.78 |
| Max. Negotiated Rate |
$550.00 |
| Rate for Payer: Aetna Commercial |
$457.37
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$129.78
|
| Rate for Payer: Anthem Medicaid |
$169.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$550.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cash Price |
$275.00
|
| Rate for Payer: Cigna Commercial |
$538.97
|
| Rate for Payer: Healthspan PPO |
$483.39
|
| Rate for Payer: Humana Medicaid |
$169.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$408.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.53
|
| Rate for Payer: Molina Healthcare Passport |
$169.15
|
| Rate for Payer: Multiplan PHCS |
$330.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.00
|
| Rate for Payer: UHCCP Medicaid |
$136.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.84
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM(T
|
Facility
|
OP
|
$801.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
761T0153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem Medicaid |
$275.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$543.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$760.35
|
| Rate for Payer: CareSource Just4Me Medicare |
$733.20
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Humana KY Medicaid |
$275.46
|
| Rate for Payer: Humana Medicare Advantage |
$543.11
|
| Rate for Payer: Kentucky WC Medicaid |
$278.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$651.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
CPLX RPR SC - EXT 2.6-7.5 CM(T
|
Facility
|
IP
|
$801.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
761T0153
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$104.13 |
| Max. Negotiated Rate |
$768.96 |
| Rate for Payer: Aetna Commercial |
$616.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.78
|
| Rate for Payer: Cash Price |
$400.50
|
| Rate for Payer: Cigna Commercial |
$664.83
|
| Rate for Payer: First Health Commercial |
$760.95
|
| Rate for Payer: Humana Commercial |
$680.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$591.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.88
|
| Rate for Payer: Ohio Health Group HMO |
$600.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.31
|
| Rate for Payer: PHCS Commercial |
$768.96
|
| Rate for Payer: United Healthcare All Payer |
$704.88
|
|
|
CPO MEDICARE/HOSP 15-29 MIN(P
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
510P0094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$118.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.67
|
| Rate for Payer: Healthspan PPO |
$77.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.22
|
| Rate for Payer: Multiplan PHCS |
$70.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.60
|
| Rate for Payer: UHCCP Medicaid |
$41.30
|
|
|
CPO MEDICARE/HOSPICE 15-29 MIN
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
51000094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
CPO MEDICARE/HOSPICE 15-29 MIN
|
Professional
|
Both
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
51000094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna Commercial |
$87.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$118.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.67
|
| Rate for Payer: Healthspan PPO |
$77.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$76.22
|
| Rate for Payer: Multiplan PHCS |
$70.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.60
|
| Rate for Payer: UHCCP Medicaid |
$41.30
|
|
|
CPO MEDICARE/HOSPICE 15-29 MIN
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 99377
|
| Hospital Charge Code |
51000094
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$15.34 |
| Max. Negotiated Rate |
$113.28 |
| Rate for Payer: Aetna Commercial |
$90.86
|
| Rate for Payer: Anthem Medicaid |
$40.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$92.04
|
| Rate for Payer: Cash Price |
$59.00
|
| Rate for Payer: Cigna Commercial |
$97.94
|
| Rate for Payer: First Health Commercial |
$112.10
|
| Rate for Payer: Humana Commercial |
$100.30
|
| Rate for Payer: Humana KY Medicaid |
$40.58
|
| Rate for Payer: Kentucky WC Medicaid |
$40.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$96.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$87.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$41.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$103.84
|
| Rate for Payer: Ohio Health Group HMO |
$88.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.58
|
| Rate for Payer: PHCS Commercial |
$113.28
|
| Rate for Payer: United Healthcare All Payer |
$103.84
|
|
|
[C]PROMETH WITH CODEINE S 10ML
|
Facility
|
OP
|
$60.57
|
|
|
Service Code
|
NDC 27808006502
|
| Hospital Charge Code |
25000116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$58.15 |
| Rate for Payer: Aetna Commercial |
$46.64
|
| Rate for Payer: Anthem Medicaid |
$20.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.24
|
| Rate for Payer: Cash Price |
$30.28
|
| Rate for Payer: Cigna Commercial |
$50.27
|
| Rate for Payer: First Health Commercial |
$57.54
|
| Rate for Payer: Humana Commercial |
$51.48
|
| Rate for Payer: Humana KY Medicaid |
$20.83
|
| Rate for Payer: Kentucky WC Medicaid |
$21.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.30
|
| Rate for Payer: Ohio Health Group HMO |
$45.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.78
|
| Rate for Payer: PHCS Commercial |
$58.15
|
| Rate for Payer: United Healthcare All Payer |
$53.30
|
|
|
[C]PROMETH WITH CODEINE S 10ML
|
Facility
|
IP
|
$60.57
|
|
|
Service Code
|
NDC 27808006502
|
| Hospital Charge Code |
25000116
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.87 |
| Max. Negotiated Rate |
$58.15 |
| Rate for Payer: Aetna Commercial |
$46.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.24
|
| Rate for Payer: Cash Price |
$30.28
|
| Rate for Payer: Cigna Commercial |
$50.27
|
| Rate for Payer: First Health Commercial |
$57.54
|
| Rate for Payer: Humana Commercial |
$51.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.30
|
| Rate for Payer: Ohio Health Group HMO |
$45.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.11
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.78
|
| Rate for Payer: PHCS Commercial |
$58.15
|
| Rate for Payer: United Healthcare All Payer |
$53.30
|
|
|
CPS AIM SL CATH 26*59CM
|
Facility
|
OP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem Medicaid |
$692.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Humana KY Medicaid |
$692.96
|
| Rate for Payer: Kentucky WC Medicaid |
$700.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$706.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 26*59CM
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 27*59CM
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 27*59CM
|
Facility
|
OP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem Medicaid |
$692.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Humana KY Medicaid |
$692.96
|
| Rate for Payer: Kentucky WC Medicaid |
$700.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$706.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 28*59CM
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 28*59CM
|
Facility
|
OP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem Medicaid |
$692.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Humana KY Medicaid |
$692.96
|
| Rate for Payer: Kentucky WC Medicaid |
$700.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$706.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 29*65CM
|
Facility
|
OP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem Medicaid |
$692.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Humana KY Medicaid |
$692.96
|
| Rate for Payer: Kentucky WC Medicaid |
$700.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$706.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL CATH 29*65CM
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
|
CPS AIM SL SUB-ACU 135A 65CM
|
Facility
|
IP
|
$2,015.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$261.95 |
| Max. Negotiated Rate |
$1,934.40 |
| Rate for Payer: Aetna Commercial |
$1,551.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,571.70
|
| Rate for Payer: Cash Price |
$1,007.50
|
| Rate for Payer: Cigna Commercial |
$1,672.45
|
| Rate for Payer: First Health Commercial |
$1,914.25
|
| Rate for Payer: Humana Commercial |
$1,712.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,652.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,487.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$604.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,773.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,511.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$624.65
|
| Rate for Payer: PHCS Commercial |
$1,934.40
|
| Rate for Payer: United Healthcare All Payer |
$1,773.20
|
|
