|
DIALYSIS CIRCUIT EMBOLJ
|
Facility
|
IP
|
$405.00
|
|
|
Service Code
|
HCPCS 36909
|
| Hospital Charge Code |
76101522
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.65 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna Commercial |
$311.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$315.90
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$336.15
|
| Rate for Payer: First Health Commercial |
$384.75
|
| Rate for Payer: Humana Commercial |
$344.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$332.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$298.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$356.40
|
| Rate for Payer: Ohio Health Group HMO |
$303.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.55
|
| Rate for Payer: PHCS Commercial |
$388.80
|
| Rate for Payer: United Healthcare All Payer |
$356.40
|
|
|
DIALYSIS CIRCUIT EMBOLJ
|
Facility
|
OP
|
$405.00
|
|
|
Service Code
|
HCPCS 36909
|
| Hospital Charge Code |
76101522
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$52.65 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna Commercial |
$311.85
|
| Rate for Payer: Anthem Medicaid |
$139.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$315.90
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$336.15
|
| Rate for Payer: First Health Commercial |
$384.75
|
| Rate for Payer: Humana Commercial |
$344.25
|
| Rate for Payer: Humana KY Medicaid |
$139.28
|
| Rate for Payer: Kentucky WC Medicaid |
$140.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$332.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$298.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$121.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$142.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$356.40
|
| Rate for Payer: Ohio Health Group HMO |
$303.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$81.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$125.55
|
| Rate for Payer: PHCS Commercial |
$388.80
|
| Rate for Payer: United Healthcare All Payer |
$356.40
|
|
|
DIALYSIS CIRCUIT EMBOLJ
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
HCPCS 36909
|
| Hospital Charge Code |
76101522
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.21 |
| Max. Negotiated Rate |
$405.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$152.27
|
| Rate for Payer: Anthem Medicaid |
$145.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.00
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$297.08
|
| Rate for Payer: Humana Medicaid |
$145.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$230.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$148.11
|
| Rate for Payer: Molina Healthcare Passport |
$145.21
|
| Rate for Payer: Multiplan PHCS |
$243.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$283.50
|
| Rate for Payer: UHCCP Medicaid |
$159.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.66
|
|
|
DIALYSIS CIRCUIT EMBOLJ(P
|
Professional
|
Both
|
$405.00
|
|
|
Service Code
|
HCPCS 36909
|
| Hospital Charge Code |
761P1522
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$145.21 |
| Max. Negotiated Rate |
$405.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$152.27
|
| Rate for Payer: Anthem Medicaid |
$145.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.00
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cash Price |
$202.50
|
| Rate for Payer: Cigna Commercial |
$297.08
|
| Rate for Payer: Humana Medicaid |
$145.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$230.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$148.11
|
| Rate for Payer: Molina Healthcare Passport |
$145.21
|
| Rate for Payer: Multiplan PHCS |
$243.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$283.50
|
| Rate for Payer: UHCCP Medicaid |
$159.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$146.66
|
|
|
DIALYSIS PROCEDURE
|
Facility
|
OP
|
$3,490.20
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
88000003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$453.73 |
| Max. Negotiated Rate |
$3,350.59 |
| Rate for Payer: Aetna Commercial |
$2,687.45
|
| Rate for Payer: Anthem Medicaid |
$1,200.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,722.36
|
| Rate for Payer: Cash Price |
$1,745.10
|
| Rate for Payer: Cigna Commercial |
$2,896.87
|
| Rate for Payer: First Health Commercial |
$3,315.69
|
| Rate for Payer: Humana Commercial |
$2,966.67
|
| Rate for Payer: Humana KY Medicaid |
$1,200.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,212.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,861.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,575.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,047.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,224.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,071.38
|
| Rate for Payer: Ohio Health Group HMO |
$2,617.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$698.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$453.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,081.96
|
| Rate for Payer: PHCS Commercial |
$3,350.59
|
| Rate for Payer: United Healthcare All Payer |
$3,071.38
|
|
|
DIALYSIS PROCEDURE
|
Facility
|
IP
|
$3,490.20
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
88000003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$453.73 |
| Max. Negotiated Rate |
$3,350.59 |
| Rate for Payer: Aetna Commercial |
$2,687.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,722.36
|
| Rate for Payer: Cash Price |
$1,745.10
|
| Rate for Payer: Cigna Commercial |
$2,896.87
|
| Rate for Payer: First Health Commercial |
$3,315.69
|
| Rate for Payer: Humana Commercial |
$2,966.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,861.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,575.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,047.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,071.38
|
| Rate for Payer: Ohio Health Group HMO |
$2,617.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$698.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$453.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,081.96
|
| Rate for Payer: PHCS Commercial |
$3,350.59
|
| Rate for Payer: United Healthcare All Payer |
$3,071.38
|
|
|
DIALYSIS PROCEDURE
|
Professional
|
Both
|
$3,490.20
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
88000003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$3,490.20 |
| Rate for Payer: Buckeye Medicare Advantage |
$3,490.20
|
| Rate for Payer: Cash Price |
$1,745.10
|
| Rate for Payer: Cash Price |
$1,745.10
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$2,094.12
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,443.14
|
| Rate for Payer: UHCCP Medicaid |
$1,221.57
|
|
|
DIALYSIS PROCEDURE(P
|
Professional
|
Both
|
$2,180.00
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
880P0003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2,180.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$2,180.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Cash Price |
$1,090.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$1,308.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,526.00
|
| Rate for Payer: UHCCP Medicaid |
$763.00
|
|
|
DIALYSIS PROCEDURE(T
|
Facility
|
OP
|
$1,310.20
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
880T0003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$170.33 |
| Max. Negotiated Rate |
$1,257.79 |
| Rate for Payer: Aetna Commercial |
$1,008.85
|
| Rate for Payer: Anthem Medicaid |
$450.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,021.96
|
| Rate for Payer: Cash Price |
$655.10
|
| Rate for Payer: Cigna Commercial |
$1,087.47
|
| Rate for Payer: First Health Commercial |
$1,244.69
|
| Rate for Payer: Humana Commercial |
$1,113.67
|
| Rate for Payer: Humana KY Medicaid |
$450.58
|
| Rate for Payer: Kentucky WC Medicaid |
$455.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,074.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$966.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$393.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$459.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,152.98
|
| Rate for Payer: Ohio Health Group HMO |
$982.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$406.16
|
| Rate for Payer: PHCS Commercial |
$1,257.79
|
| Rate for Payer: United Healthcare All Payer |
$1,152.98
|
|
|
DIALYSIS PROCEDURE(T
|
Facility
|
IP
|
$1,310.20
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
880T0003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$170.33 |
| Max. Negotiated Rate |
$1,257.79 |
| Rate for Payer: Aetna Commercial |
$1,008.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,021.96
|
| Rate for Payer: Cash Price |
$655.10
|
| Rate for Payer: Cigna Commercial |
$1,087.47
|
| Rate for Payer: First Health Commercial |
$1,244.69
|
| Rate for Payer: Humana Commercial |
$1,113.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,074.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$966.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$393.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,152.98
|
| Rate for Payer: Ohio Health Group HMO |
$982.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$262.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$170.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$406.16
|
| Rate for Payer: PHCS Commercial |
$1,257.79
|
| Rate for Payer: United Healthcare All Payer |
$1,152.98
|
|
|
DIAMONDBACK 1.25*145
|
Facility
|
OP
|
$16,422.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,134.86 |
| Max. Negotiated Rate |
$15,765.12 |
| Rate for Payer: Aetna Commercial |
$12,644.94
|
| Rate for Payer: Anthem Medicaid |
$5,647.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,809.16
|
| Rate for Payer: Cash Price |
$8,211.00
|
| Rate for Payer: Cigna Commercial |
$13,630.26
|
| Rate for Payer: First Health Commercial |
$15,600.90
|
| Rate for Payer: Humana Commercial |
$13,958.70
|
| Rate for Payer: Humana KY Medicaid |
$5,647.53
|
| Rate for Payer: Kentucky WC Medicaid |
$5,705.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,466.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,119.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,926.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,760.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,451.36
|
| Rate for Payer: Ohio Health Group HMO |
$12,316.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,284.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,134.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,090.82
|
| Rate for Payer: PHCS Commercial |
$15,765.12
|
| Rate for Payer: United Healthcare All Payer |
$14,451.36
|
|
|
DIAMONDBACK 1.25*145
|
Facility
|
IP
|
$16,422.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,134.86 |
| Max. Negotiated Rate |
$15,765.12 |
| Rate for Payer: Aetna Commercial |
$12,644.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,809.16
|
| Rate for Payer: Cash Price |
$8,211.00
|
| Rate for Payer: Cigna Commercial |
$13,630.26
|
| Rate for Payer: First Health Commercial |
$15,600.90
|
| Rate for Payer: Humana Commercial |
$13,958.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,466.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,119.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,926.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,451.36
|
| Rate for Payer: Ohio Health Group HMO |
$12,316.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,284.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,134.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,090.82
|
| Rate for Payer: PHCS Commercial |
$15,765.12
|
| Rate for Payer: United Healthcare All Payer |
$14,451.36
|
|
|
DIAMONDBACK 1.25*60
|
Facility
|
OP
|
$17,862.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,322.06 |
| Max. Negotiated Rate |
$17,147.52 |
| Rate for Payer: Anthem Medicaid |
$6,142.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,932.36
|
| Rate for Payer: Cash Price |
$8,931.00
|
| Rate for Payer: Cigna Commercial |
$14,825.46
|
| Rate for Payer: First Health Commercial |
$16,968.90
|
| Rate for Payer: Humana Commercial |
$15,182.70
|
| Rate for Payer: Humana KY Medicaid |
$6,142.74
|
| Rate for Payer: Kentucky WC Medicaid |
$6,205.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,646.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,182.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,358.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,265.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,718.56
|
| Rate for Payer: Ohio Health Group HMO |
$13,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,572.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,322.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,537.22
|
| Rate for Payer: PHCS Commercial |
$17,147.52
|
| Rate for Payer: United Healthcare All Payer |
$15,718.56
|
| Rate for Payer: Aetna Commercial |
$13,753.74
|
|
|
DIAMONDBACK 1.25*60
|
Facility
|
IP
|
$17,862.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,322.06 |
| Max. Negotiated Rate |
$17,147.52 |
| Rate for Payer: Aetna Commercial |
$13,753.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,932.36
|
| Rate for Payer: Cash Price |
$8,931.00
|
| Rate for Payer: Cigna Commercial |
$14,825.46
|
| Rate for Payer: First Health Commercial |
$16,968.90
|
| Rate for Payer: Humana Commercial |
$15,182.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,646.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,182.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,358.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,718.56
|
| Rate for Payer: Ohio Health Group HMO |
$13,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,572.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,322.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,537.22
|
| Rate for Payer: PHCS Commercial |
$17,147.52
|
| Rate for Payer: United Healthcare All Payer |
$15,718.56
|
|
|
DIAMONDBACK 360 CLASSIC 1.25
|
Facility
|
IP
|
$18,582.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,415.66 |
| Max. Negotiated Rate |
$17,838.72 |
| Rate for Payer: Aetna Commercial |
$14,308.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,493.96
|
| Rate for Payer: Cash Price |
$9,291.00
|
| Rate for Payer: Cigna Commercial |
$15,423.06
|
| Rate for Payer: First Health Commercial |
$17,652.90
|
| Rate for Payer: Humana Commercial |
$15,794.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,237.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,713.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,574.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,352.16
|
| Rate for Payer: Ohio Health Group HMO |
$13,936.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,716.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,415.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,760.42
|
| Rate for Payer: PHCS Commercial |
$17,838.72
|
| Rate for Payer: United Healthcare All Payer |
$16,352.16
|
|
|
DIAMONDBACK 360 CLASSIC 1.25
|
Facility
|
OP
|
$18,582.00
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,415.66 |
| Max. Negotiated Rate |
$17,838.72 |
| Rate for Payer: Aetna Commercial |
$14,308.14
|
| Rate for Payer: Anthem Medicaid |
$6,390.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,493.96
|
| Rate for Payer: Cash Price |
$9,291.00
|
| Rate for Payer: Cigna Commercial |
$15,423.06
|
| Rate for Payer: First Health Commercial |
$17,652.90
|
| Rate for Payer: Humana Commercial |
$15,794.70
|
| Rate for Payer: Humana KY Medicaid |
$6,390.35
|
| Rate for Payer: Kentucky WC Medicaid |
$6,455.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,237.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,713.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,574.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,518.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,352.16
|
| Rate for Payer: Ohio Health Group HMO |
$13,936.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,716.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,415.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,760.42
|
| Rate for Payer: PHCS Commercial |
$17,838.72
|
| Rate for Payer: United Healthcare All Payer |
$16,352.16
|
|
|
DIAMOX (ACETAZOLAMI 250MG/1TAB
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
25000551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
DIAMOX (ACETAZOLAMI 250MG/1TAB
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
25000551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.41
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
DIAMOX (ACETAZOLAMID 500MG/5ML
|
Facility
|
IP
|
$199.96
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
25002019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$191.96 |
| Rate for Payer: Aetna Commercial |
$153.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.97
|
| Rate for Payer: Cash Price |
$99.98
|
| Rate for Payer: Cigna Commercial |
$165.97
|
| Rate for Payer: First Health Commercial |
$189.96
|
| Rate for Payer: Humana Commercial |
$169.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.96
|
| Rate for Payer: Ohio Health Group HMO |
$149.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.99
|
| Rate for Payer: PHCS Commercial |
$191.96
|
| Rate for Payer: United Healthcare All Payer |
$175.96
|
|
|
DIAMOX (ACETAZOLAMID 500MG/5ML
|
Facility
|
OP
|
$199.96
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
25002019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.99 |
| Max. Negotiated Rate |
$191.96 |
| Rate for Payer: Aetna Commercial |
$153.97
|
| Rate for Payer: Anthem Medicaid |
$68.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.97
|
| Rate for Payer: Cash Price |
$99.98
|
| Rate for Payer: Cigna Commercial |
$165.97
|
| Rate for Payer: First Health Commercial |
$189.96
|
| Rate for Payer: Humana Commercial |
$169.97
|
| Rate for Payer: Humana KY Medicaid |
$68.77
|
| Rate for Payer: Kentucky WC Medicaid |
$69.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.96
|
| Rate for Payer: Ohio Health Group HMO |
$149.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$61.99
|
| Rate for Payer: PHCS Commercial |
$191.96
|
| Rate for Payer: United Healthcare All Payer |
$175.96
|
|
|
DIANEAL PD1.5D Mg0.53.5Ca 2.5L
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$26.69 |
| Rate for Payer: Aetna Commercial |
$21.41
|
| Rate for Payer: Anthem Medicaid |
$9.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.68
|
| Rate for Payer: Cash Price |
$13.90
|
| Rate for Payer: Cigna Commercial |
$23.07
|
| Rate for Payer: First Health Commercial |
$26.41
|
| Rate for Payer: Humana Commercial |
$23.63
|
| Rate for Payer: Humana KY Medicaid |
$9.56
|
| Rate for Payer: Kentucky WC Medicaid |
$9.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.46
|
| Rate for Payer: Ohio Health Group HMO |
$20.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.62
|
| Rate for Payer: PHCS Commercial |
$26.69
|
| Rate for Payer: United Healthcare All Payer |
$24.46
|
|
|
DIANEAL PD1.5D Mg0.53.5Ca 2.5L
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004374
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$26.69 |
| Rate for Payer: Aetna Commercial |
$21.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.68
|
| Rate for Payer: Cash Price |
$13.90
|
| Rate for Payer: Cigna Commercial |
$23.07
|
| Rate for Payer: First Health Commercial |
$26.41
|
| Rate for Payer: Humana Commercial |
$23.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.46
|
| Rate for Payer: Ohio Health Group HMO |
$20.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.62
|
| Rate for Payer: PHCS Commercial |
$26.69
|
| Rate for Payer: United Healthcare All Payer |
$24.46
|
|
|
DIAPHYSEAL ELLIP OSS SEG 3CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL ELLIP OSS SEG 3CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DIAPHYSEAL OSS SEG 11CM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
