|
DELTA XTEND HUM SZ 2 D10 LG
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DELTA XTEND HUM SZ 2 D10 LG
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DELTA XTEND HUM SZ 2 D14 LG
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DELTA XTEND HUM SZ 2 D14 LG
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
DELTA XTEND MOD CENT EPI 2 HA
|
Facility
|
IP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND MOD CENT EPI 2 HA
|
Facility
|
OP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem Medicaid |
$9,891.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Humana KY Medicaid |
$9,891.85
|
| Rate for Payer: Kentucky WC Medicaid |
$9,992.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,090.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND MOD EPI 1 ECC LT H
|
Facility
|
IP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND MOD EPI 1 ECC LT H
|
Facility
|
OP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem Medicaid |
$9,891.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Humana KY Medicaid |
$9,891.85
|
| Rate for Payer: Kentucky WC Medicaid |
$9,992.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,090.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND MOD EPI 1 ECC RT H
|
Facility
|
IP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND MOD EPI 1 ECC RT H
|
Facility
|
OP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem Medicaid |
$9,891.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Humana KY Medicaid |
$9,891.85
|
| Rate for Payer: Kentucky WC Medicaid |
$9,992.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,090.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND MODEPI 2 ECC LT HA
|
Facility
|
IP
|
$26,528.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,958.62 |
| Max. Negotiated Rate |
$25,467.60 |
| Rate for Payer: Aetna Commercial |
$20,427.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,692.42
|
| Rate for Payer: Cash Price |
$13,264.38
|
| Rate for Payer: Cigna Commercial |
$22,018.86
|
| Rate for Payer: First Health Commercial |
$25,202.31
|
| Rate for Payer: Humana Commercial |
$22,549.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,753.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,578.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,958.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,345.30
|
| Rate for Payer: Ohio Health Group HMO |
$19,896.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,223.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,080.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,304.84
|
| Rate for Payer: PHCS Commercial |
$25,467.60
|
| Rate for Payer: United Healthcare All Payer |
$23,345.30
|
|
|
DELTA XTEND MODEPI 2 ECC LT HA
|
Facility
|
OP
|
$26,528.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,958.62 |
| Max. Negotiated Rate |
$25,467.60 |
| Rate for Payer: Aetna Commercial |
$20,427.14
|
| Rate for Payer: Anthem Medicaid |
$9,123.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,692.42
|
| Rate for Payer: Cash Price |
$13,264.38
|
| Rate for Payer: Cigna Commercial |
$22,018.86
|
| Rate for Payer: First Health Commercial |
$25,202.31
|
| Rate for Payer: Humana Commercial |
$22,549.44
|
| Rate for Payer: Humana KY Medicaid |
$9,123.24
|
| Rate for Payer: Kentucky WC Medicaid |
$9,216.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,753.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,578.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,958.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,306.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,345.30
|
| Rate for Payer: Ohio Health Group HMO |
$19,896.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,223.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,080.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,304.84
|
| Rate for Payer: PHCS Commercial |
$25,467.60
|
| Rate for Payer: United Healthcare All Payer |
$23,345.30
|
|
|
DELTA XTEND MODEPI 2 ECC RT HA
|
Facility
|
OP
|
$27,391.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,217.38 |
| Max. Negotiated Rate |
$26,295.60 |
| Rate for Payer: Aetna Commercial |
$21,091.26
|
| Rate for Payer: Anthem Medicaid |
$9,419.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,365.17
|
| Rate for Payer: Cash Price |
$13,695.62
|
| Rate for Payer: Cigna Commercial |
$22,734.74
|
| Rate for Payer: First Health Commercial |
$26,021.69
|
| Rate for Payer: Humana Commercial |
$23,282.56
|
| Rate for Payer: Humana KY Medicaid |
$9,419.85
|
| Rate for Payer: Kentucky WC Medicaid |
$9,515.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,460.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,214.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,217.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,608.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,104.30
|
| Rate for Payer: Ohio Health Group HMO |
$20,543.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,913.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,830.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,899.96
|
| Rate for Payer: PHCS Commercial |
$26,295.60
|
| Rate for Payer: United Healthcare All Payer |
$24,104.30
|
|
|
DELTA XTEND MODEPI 2 ECC RT HA
|
Facility
|
IP
|
$27,391.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,217.38 |
| Max. Negotiated Rate |
$26,295.60 |
| Rate for Payer: Aetna Commercial |
$21,091.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,365.17
|
| Rate for Payer: Cash Price |
$13,695.62
|
| Rate for Payer: Cigna Commercial |
$22,734.74
|
| Rate for Payer: First Health Commercial |
$26,021.69
|
| Rate for Payer: Humana Commercial |
$23,282.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,460.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,214.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,217.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,104.30
|
| Rate for Payer: Ohio Health Group HMO |
$20,543.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,913.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,830.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,899.96
|
| Rate for Payer: PHCS Commercial |
$26,295.60
|
| Rate for Payer: United Healthcare All Payer |
$24,104.30
|
|
|
DELTA XTEND SZ 1
|
Facility
|
IP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTA XTEND SZ 1
|
Facility
|
OP
|
$28,763.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,629.12 |
| Max. Negotiated Rate |
$27,613.20 |
| Rate for Payer: Aetna Commercial |
$22,148.09
|
| Rate for Payer: Anthem Medicaid |
$9,891.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,435.72
|
| Rate for Payer: Cash Price |
$14,381.88
|
| Rate for Payer: Cigna Commercial |
$23,873.91
|
| Rate for Payer: First Health Commercial |
$27,325.56
|
| Rate for Payer: Humana Commercial |
$24,449.19
|
| Rate for Payer: Humana KY Medicaid |
$9,891.85
|
| Rate for Payer: Kentucky WC Medicaid |
$9,992.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,586.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,227.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,629.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,090.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,312.10
|
| Rate for Payer: Ohio Health Group HMO |
$21,572.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23,011.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25,024.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,846.99
|
| Rate for Payer: PHCS Commercial |
$27,613.20
|
| Rate for Payer: United Healthcare All Payer |
$25,312.10
|
|
|
DELTOID LIGMNT RECON IMP SYS
|
Facility
|
IP
|
$10,135.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,040.72 |
| Max. Negotiated Rate |
$9,730.32 |
| Rate for Payer: Aetna Commercial |
$7,804.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,905.89
|
| Rate for Payer: Cash Price |
$5,067.88
|
| Rate for Payer: Cigna Commercial |
$8,412.67
|
| Rate for Payer: First Health Commercial |
$9,628.96
|
| Rate for Payer: Humana Commercial |
$8,615.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,311.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,480.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,919.46
|
| Rate for Payer: Ohio Health Group HMO |
$7,601.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,108.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,818.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,993.67
|
| Rate for Payer: PHCS Commercial |
$9,730.32
|
| Rate for Payer: United Healthcare All Payer |
$8,919.46
|
|
|
DELTOID LIGMNT RECON IMP SYS
|
Facility
|
OP
|
$10,135.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,040.72 |
| Max. Negotiated Rate |
$9,730.32 |
| Rate for Payer: Aetna Commercial |
$7,804.53
|
| Rate for Payer: Anthem Medicaid |
$3,485.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,905.89
|
| Rate for Payer: Cash Price |
$5,067.88
|
| Rate for Payer: Cigna Commercial |
$8,412.67
|
| Rate for Payer: First Health Commercial |
$9,628.96
|
| Rate for Payer: Humana Commercial |
$8,615.39
|
| Rate for Payer: Humana KY Medicaid |
$3,485.68
|
| Rate for Payer: Kentucky WC Medicaid |
$3,521.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,311.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,480.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,040.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,555.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,919.46
|
| Rate for Payer: Ohio Health Group HMO |
$7,601.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,108.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,818.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,993.67
|
| Rate for Payer: PHCS Commercial |
$9,730.32
|
| Rate for Payer: United Healthcare All Payer |
$8,919.46
|
|
|
DELZICOL 400 MG CAPSULE
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 59762011701
|
| Hospital Charge Code |
25000526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
DELZICOL 400 MG CAPSULE
|
Facility
|
OP
|
$10.33
|
|
|
Service Code
|
NDC 59762011701
|
| Hospital Charge Code |
25000526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$9.92 |
| Rate for Payer: Aetna Commercial |
$7.95
|
| Rate for Payer: Anthem Medicaid |
$3.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.06
|
| Rate for Payer: Cash Price |
$5.16
|
| Rate for Payer: Cigna Commercial |
$8.57
|
| Rate for Payer: First Health Commercial |
$9.81
|
| Rate for Payer: Humana Commercial |
$8.78
|
| Rate for Payer: Humana KY Medicaid |
$3.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.47
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.09
|
| Rate for Payer: Ohio Health Group HMO |
$7.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$9.92
|
| Rate for Payer: United Healthcare All Payer |
$9.09
|
|
|
DEMADEX (TORSEMIDE) 20MG/1TAB
|
Facility
|
IP
|
$4.56
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
25000527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
DEMADEX (TORSEMIDE) 20MG/1TAB
|
Facility
|
OP
|
$4.56
|
|
|
Service Code
|
NDC 68084053901
|
| Hospital Charge Code |
25000527
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.38 |
| Rate for Payer: Aetna Commercial |
$3.51
|
| Rate for Payer: Anthem Medicaid |
$1.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.33
|
| Rate for Payer: Humana Commercial |
$3.88
|
| Rate for Payer: Humana KY Medicaid |
$1.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.01
|
| Rate for Payer: Ohio Health Group HMO |
$3.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.15
|
| Rate for Payer: PHCS Commercial |
$4.38
|
| Rate for Payer: United Healthcare All Payer |
$4.01
|
|
|
DEMEROL 100MG(25MG SYR)
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25004553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Kentucky WC Medicaid |
$26.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
DEMEROL 100MG(25MG SYR)
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25004553
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.50 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51.75
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
DEMEROL [100 MG] 50MG/1ML INJ
|
Facility
|
OP
|
$77.32
|
|
|
Service Code
|
HCPCS J2175
|
| Hospital Charge Code |
25002222
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$74.23 |
| Rate for Payer: Aetna Commercial |
$59.54
|
| Rate for Payer: Anthem Medicaid |
$26.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$60.31
|
| Rate for Payer: Cash Price |
$38.66
|
| Rate for Payer: Cigna Commercial |
$64.18
|
| Rate for Payer: First Health Commercial |
$73.45
|
| Rate for Payer: Humana Commercial |
$65.72
|
| Rate for Payer: Humana KY Medicaid |
$26.59
|
| Rate for Payer: Kentucky WC Medicaid |
$26.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$63.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$57.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$27.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$68.04
|
| Rate for Payer: Ohio Health Group HMO |
$57.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$61.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$53.35
|
| Rate for Payer: PHCS Commercial |
$74.23
|
| Rate for Payer: United Healthcare All Payer |
$68.04
|
|
