|
DIST FEM AUG BLOCK #3/5MM
|
Facility
|
OP
|
$5,042.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$655.46 |
| Max. Negotiated Rate |
$4,840.32 |
| Rate for Payer: Aetna Commercial |
$3,882.34
|
| Rate for Payer: Anthem Medicaid |
$1,733.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,932.76
|
| Rate for Payer: Cash Price |
$2,521.00
|
| Rate for Payer: Cigna Commercial |
$4,184.86
|
| Rate for Payer: First Health Commercial |
$4,789.90
|
| Rate for Payer: Humana Commercial |
$4,285.70
|
| Rate for Payer: Humana KY Medicaid |
$1,733.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,751.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,134.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,721.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,512.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,768.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,436.96
|
| Rate for Payer: Ohio Health Group HMO |
$3,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,008.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$655.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,563.02
|
| Rate for Payer: PHCS Commercial |
$4,840.32
|
| Rate for Payer: United Healthcare All Payer |
$4,436.96
|
|
|
DIST FEM AUG BLOCK #5/10MM
|
Facility
|
IP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #5/10MM
|
Facility
|
OP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem Medicaid |
$1,917.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Humana KY Medicaid |
$1,917.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,937.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,956.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #5/15MM
|
Facility
|
IP
|
$5,386.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$700.23 |
| Max. Negotiated Rate |
$5,170.94 |
| Rate for Payer: Aetna Commercial |
$4,147.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,201.39
|
| Rate for Payer: Cash Price |
$2,693.20
|
| Rate for Payer: Cigna Commercial |
$4,470.71
|
| Rate for Payer: First Health Commercial |
$5,117.08
|
| Rate for Payer: Humana Commercial |
$4,578.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,416.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,975.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,615.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,740.03
|
| Rate for Payer: Ohio Health Group HMO |
$4,039.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,077.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$700.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,669.78
|
| Rate for Payer: PHCS Commercial |
$5,170.94
|
| Rate for Payer: United Healthcare All Payer |
$4,740.03
|
|
|
DIST FEM AUG BLOCK #5/15MM
|
Facility
|
OP
|
$5,386.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$700.23 |
| Max. Negotiated Rate |
$5,170.94 |
| Rate for Payer: Aetna Commercial |
$4,147.53
|
| Rate for Payer: Anthem Medicaid |
$1,852.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,201.39
|
| Rate for Payer: Cash Price |
$2,693.20
|
| Rate for Payer: Cigna Commercial |
$4,470.71
|
| Rate for Payer: First Health Commercial |
$5,117.08
|
| Rate for Payer: Humana Commercial |
$4,578.44
|
| Rate for Payer: Humana KY Medicaid |
$1,852.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1,871.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,416.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,975.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,615.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,889.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,740.03
|
| Rate for Payer: Ohio Health Group HMO |
$4,039.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,077.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$700.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,669.78
|
| Rate for Payer: PHCS Commercial |
$5,170.94
|
| Rate for Payer: United Healthcare All Payer |
$4,740.03
|
|
|
DIST FEM AUG BLOCK #5/5MM
|
Facility
|
OP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem Medicaid |
$1,917.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Humana KY Medicaid |
$1,917.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,937.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,956.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #5/5MM
|
Facility
|
IP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #7/10MM
|
Facility
|
OP
|
$6,531.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.13 |
| Max. Negotiated Rate |
$6,270.49 |
| Rate for Payer: Aetna Commercial |
$5,029.46
|
| Rate for Payer: Anthem Medicaid |
$2,246.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,094.77
|
| Rate for Payer: Cash Price |
$3,265.88
|
| Rate for Payer: Cigna Commercial |
$5,421.36
|
| Rate for Payer: First Health Commercial |
$6,205.17
|
| Rate for Payer: Humana Commercial |
$5,552.00
|
| Rate for Payer: Humana KY Medicaid |
$2,246.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,269.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,356.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,820.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,959.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,291.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,747.95
|
| Rate for Payer: Ohio Health Group HMO |
$4,898.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,306.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,024.85
|
| Rate for Payer: PHCS Commercial |
$6,270.49
|
| Rate for Payer: United Healthcare All Payer |
$5,747.95
|
|
|
DIST FEM AUG BLOCK #7/10MM
|
Facility
|
IP
|
$6,531.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.13 |
| Max. Negotiated Rate |
$6,270.49 |
| Rate for Payer: Aetna Commercial |
$5,029.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,094.77
|
| Rate for Payer: Cash Price |
$3,265.88
|
| Rate for Payer: Cigna Commercial |
$5,421.36
|
| Rate for Payer: First Health Commercial |
$6,205.17
|
| Rate for Payer: Humana Commercial |
$5,552.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,356.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,820.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,959.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,747.95
|
| Rate for Payer: Ohio Health Group HMO |
$4,898.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,306.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,024.85
|
| Rate for Payer: PHCS Commercial |
$6,270.49
|
| Rate for Payer: United Healthcare All Payer |
$5,747.95
|
|
|
DIST FEM AUG BLOCK #7/15MM
|
Facility
|
IP
|
$6,531.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.13 |
| Max. Negotiated Rate |
$6,270.49 |
| Rate for Payer: Aetna Commercial |
$5,029.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,094.77
|
| Rate for Payer: Cash Price |
$3,265.88
|
| Rate for Payer: Cigna Commercial |
$5,421.36
|
| Rate for Payer: First Health Commercial |
$6,205.17
|
| Rate for Payer: Humana Commercial |
$5,552.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,356.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,820.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,959.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,747.95
|
| Rate for Payer: Ohio Health Group HMO |
$4,898.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,306.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,024.85
|
| Rate for Payer: PHCS Commercial |
$6,270.49
|
| Rate for Payer: United Healthcare All Payer |
$5,747.95
|
|
|
DIST FEM AUG BLOCK #7/15MM
|
Facility
|
OP
|
$6,531.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$849.13 |
| Max. Negotiated Rate |
$6,270.49 |
| Rate for Payer: Aetna Commercial |
$5,029.46
|
| Rate for Payer: Anthem Medicaid |
$2,246.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,094.77
|
| Rate for Payer: Cash Price |
$3,265.88
|
| Rate for Payer: Cigna Commercial |
$5,421.36
|
| Rate for Payer: First Health Commercial |
$6,205.17
|
| Rate for Payer: Humana Commercial |
$5,552.00
|
| Rate for Payer: Humana KY Medicaid |
$2,246.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,269.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,356.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,820.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,959.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,291.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,747.95
|
| Rate for Payer: Ohio Health Group HMO |
$4,898.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,306.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$849.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,024.85
|
| Rate for Payer: PHCS Commercial |
$6,270.49
|
| Rate for Payer: United Healthcare All Payer |
$5,747.95
|
|
|
DIST FEM AUG BLOCK #7/5MM
|
Facility
|
OP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem Medicaid |
$1,917.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Humana KY Medicaid |
$1,917.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,937.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,956.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #7/5MM
|
Facility
|
IP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #9/10MM
|
Facility
|
OP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem Medicaid |
$1,917.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Humana KY Medicaid |
$1,917.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,937.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,956.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #9/10MM
|
Facility
|
IP
|
$5,576.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.98 |
| Max. Negotiated Rate |
$5,353.73 |
| Rate for Payer: Aetna Commercial |
$4,294.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,349.90
|
| Rate for Payer: Cash Price |
$2,788.40
|
| Rate for Payer: Cigna Commercial |
$4,628.74
|
| Rate for Payer: First Health Commercial |
$5,297.96
|
| Rate for Payer: Humana Commercial |
$4,740.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,572.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,115.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,907.58
|
| Rate for Payer: Ohio Health Group HMO |
$4,182.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,115.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,728.81
|
| Rate for Payer: PHCS Commercial |
$5,353.73
|
| Rate for Payer: United Healthcare All Payer |
$4,907.58
|
|
|
DIST FEM AUG BLOCK #9/15MM
|
Facility
|
OP
|
$4,907.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$637.99 |
| Max. Negotiated Rate |
$4,711.30 |
| Rate for Payer: Aetna Commercial |
$3,778.85
|
| Rate for Payer: Anthem Medicaid |
$1,687.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.93
|
| Rate for Payer: Cash Price |
$2,453.80
|
| Rate for Payer: Cigna Commercial |
$4,073.31
|
| Rate for Payer: First Health Commercial |
$4,662.22
|
| Rate for Payer: Humana Commercial |
$4,171.46
|
| Rate for Payer: Humana KY Medicaid |
$1,687.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,024.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.69
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$981.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$637.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,521.36
|
| Rate for Payer: PHCS Commercial |
$4,711.30
|
| Rate for Payer: United Healthcare All Payer |
$4,318.69
|
|
|
DIST FEM AUG BLOCK #9/15MM
|
Facility
|
IP
|
$4,907.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$637.99 |
| Max. Negotiated Rate |
$4,711.30 |
| Rate for Payer: Aetna Commercial |
$3,778.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.93
|
| Rate for Payer: Cash Price |
$2,453.80
|
| Rate for Payer: Cigna Commercial |
$4,073.31
|
| Rate for Payer: First Health Commercial |
$4,662.22
|
| Rate for Payer: Humana Commercial |
$4,171.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,024.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.69
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$981.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$637.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,521.36
|
| Rate for Payer: PHCS Commercial |
$4,711.30
|
| Rate for Payer: United Healthcare All Payer |
$4,318.69
|
|
|
DIST REVAS LIGATION HEMO
|
Professional
|
Both
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
76101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$1,880.95 |
| Rate for Payer: Aetna Commercial |
$1,880.95
|
| Rate for Payer: Anthem Medicaid |
$909.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,780.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,803.52
|
| Rate for Payer: Healthspan PPO |
$1,503.99
|
| Rate for Payer: Humana Medicaid |
$909.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,565.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$927.34
|
| Rate for Payer: Molina Healthcare Passport |
$909.16
|
| Rate for Payer: Multiplan PHCS |
$1,068.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,246.00
|
| Rate for Payer: UHCCP Medicaid |
$623.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$918.25
|
|
|
DIST REVAS LIGATION HEMO
|
Facility
|
OP
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
76101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$231.40 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Aetna Commercial |
$1,370.60
|
| Rate for Payer: Anthem Medicaid |
$612.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,388.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,477.40
|
| Rate for Payer: First Health Commercial |
$1,691.00
|
| Rate for Payer: Humana Commercial |
$1,513.00
|
| Rate for Payer: Humana KY Medicaid |
$612.14
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Kentucky WC Medicaid |
$618.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,459.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,313.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$624.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,566.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,335.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.80
|
| Rate for Payer: PHCS Commercial |
$1,708.80
|
| Rate for Payer: United Healthcare All Payer |
$1,566.40
|
|
|
DIST REVAS LIGATION HEMO
|
Facility
|
IP
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
76101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$231.40 |
| Max. Negotiated Rate |
$1,708.80 |
| Rate for Payer: Aetna Commercial |
$1,370.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,388.40
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,477.40
|
| Rate for Payer: First Health Commercial |
$1,691.00
|
| Rate for Payer: Humana Commercial |
$1,513.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,459.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,313.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$534.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,566.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,335.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$356.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.80
|
| Rate for Payer: PHCS Commercial |
$1,708.80
|
| Rate for Payer: United Healthcare All Payer |
$1,566.40
|
|
|
DIST REVAS LIGATION HEMO(P
|
Professional
|
Both
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
761P1513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$1,880.95 |
| Rate for Payer: Aetna Commercial |
$1,880.95
|
| Rate for Payer: Anthem Medicaid |
$909.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,780.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,803.52
|
| Rate for Payer: Healthspan PPO |
$1,503.99
|
| Rate for Payer: Humana Medicaid |
$909.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,565.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$927.34
|
| Rate for Payer: Molina Healthcare Passport |
$909.16
|
| Rate for Payer: Multiplan PHCS |
$1,068.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,246.00
|
| Rate for Payer: UHCCP Medicaid |
$623.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$918.25
|
|
|
DISULFIRAM 250 MG TABLET
|
Facility
|
OP
|
$10.83
|
|
|
Service Code
|
NDC 47781060730
|
| Hospital Charge Code |
25003986
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna Commercial |
$8.34
|
| Rate for Payer: Anthem Medicaid |
$3.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.45
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cigna Commercial |
$8.99
|
| Rate for Payer: First Health Commercial |
$10.29
|
| Rate for Payer: Humana Commercial |
$9.21
|
| Rate for Payer: Humana KY Medicaid |
$3.72
|
| Rate for Payer: Kentucky WC Medicaid |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.53
|
| Rate for Payer: Ohio Health Group HMO |
$8.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Payer |
$9.53
|
|
|
DISULFIRAM 250 MG TABLET
|
Facility
|
IP
|
$10.83
|
|
|
Service Code
|
NDC 47781060730
|
| Hospital Charge Code |
25003986
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.45
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cigna Commercial |
$8.99
|
| Rate for Payer: First Health Commercial |
$10.29
|
| Rate for Payer: Humana Commercial |
$9.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.53
|
| Rate for Payer: Ohio Health Group HMO |
$8.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.36
|
| Rate for Payer: PHCS Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Payer |
$9.53
|
| Rate for Payer: Aetna Commercial |
$8.34
|
|
|
DITROPAN (OXYBUTYNIN) 5MG/1TAB
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 60687067001
|
| Hospital Charge Code |
25000573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: First Health Commercial |
$4.43
|
| Rate for Payer: Humana Commercial |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.10
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
|
DITROPAN (OXYBUTYNIN) 5MG/1TAB
|
Facility
|
OP
|
$4.66
|
|
|
Service Code
|
NDC 60687067001
|
| Hospital Charge Code |
25000573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: First Health Commercial |
$4.43
|
| Rate for Payer: Humana Commercial |
$3.96
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.10
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.44
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
