|
DYSPORT 5u (300u SDV)
|
Facility
|
IP
|
$2,809.48
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004362
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$365.23 |
| Max. Negotiated Rate |
$2,697.10 |
| Rate for Payer: Aetna Commercial |
$2,163.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,191.39
|
| Rate for Payer: Cash Price |
$1,404.74
|
| Rate for Payer: Cigna Commercial |
$2,331.87
|
| Rate for Payer: First Health Commercial |
$2,669.01
|
| Rate for Payer: Humana Commercial |
$2,388.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,303.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,073.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$842.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,472.34
|
| Rate for Payer: Ohio Health Group HMO |
$2,107.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$561.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$365.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$870.94
|
| Rate for Payer: PHCS Commercial |
$2,697.10
|
| Rate for Payer: United Healthcare All Payer |
$2,472.34
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
OP
|
$45.11
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem Medicaid |
$15.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.89
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cigna Commercial |
$37.44
|
| Rate for Payer: First Health Commercial |
$42.85
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Humana KY Medicaid |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$8.80
|
| Rate for Payer: Kentucky WC Medicaid |
$15.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.70
|
| Rate for Payer: Ohio Health Group HMO |
$33.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.31
|
| Rate for Payer: United Healthcare All Payer |
$39.70
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
IP
|
$45.11
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.19
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cigna Commercial |
$37.44
|
| Rate for Payer: First Health Commercial |
$42.85
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.70
|
| Rate for Payer: Ohio Health Group HMO |
$33.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.31
|
| Rate for Payer: United Healthcare All Payer |
$39.70
|
|
|
DYSPORT 5u (300u SDV)
|
Professional
|
Both
|
$45.11
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$45.11 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.11
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.70
|
| Rate for Payer: Multiplan PHCS |
$27.07
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.58
|
| Rate for Payer: UHCCP Medicaid |
$15.79
|
|
|
DYSPORT 5u (300u SDV)
|
Facility
|
IP
|
$45.11
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600188
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.31 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.19
|
| Rate for Payer: Cash Price |
$22.56
|
| Rate for Payer: Cigna Commercial |
$37.44
|
| Rate for Payer: First Health Commercial |
$42.85
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.70
|
| Rate for Payer: Ohio Health Group HMO |
$33.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.31
|
| Rate for Payer: United Healthcare All Payer |
$39.70
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
IP
|
$45.10
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.30 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.18
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cigna Commercial |
$37.43
|
| Rate for Payer: First Health Commercial |
$42.84
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.69
|
| Rate for Payer: Ohio Health Group HMO |
$33.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.30
|
| Rate for Payer: United Healthcare All Payer |
$39.69
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
OP
|
$45.10
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.30 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem Medicaid |
$15.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.89
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cigna Commercial |
$37.43
|
| Rate for Payer: First Health Commercial |
$42.84
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Humana KY Medicaid |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$8.80
|
| Rate for Payer: Kentucky WC Medicaid |
$15.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.69
|
| Rate for Payer: Ohio Health Group HMO |
$33.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.30
|
| Rate for Payer: United Healthcare All Payer |
$39.69
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
OP
|
$45.10
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.30 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem Medicaid |
$15.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.89
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cigna Commercial |
$37.43
|
| Rate for Payer: First Health Commercial |
$42.84
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Humana KY Medicaid |
$15.51
|
| Rate for Payer: Humana Medicare Advantage |
$8.80
|
| Rate for Payer: Kentucky WC Medicaid |
$15.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$15.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.69
|
| Rate for Payer: Ohio Health Group HMO |
$33.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.30
|
| Rate for Payer: United Healthcare All Payer |
$39.69
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
IP
|
$45.10
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
636T0189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$43.30 |
| Rate for Payer: Aetna Commercial |
$34.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.18
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cigna Commercial |
$37.43
|
| Rate for Payer: First Health Commercial |
$42.84
|
| Rate for Payer: Humana Commercial |
$38.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.69
|
| Rate for Payer: Ohio Health Group HMO |
$33.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.98
|
| Rate for Payer: PHCS Commercial |
$43.30
|
| Rate for Payer: United Healthcare All Payer |
$39.69
|
|
|
DYSPORT 5u (500u SDV)
|
Professional
|
Both
|
$45.10
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
63600189
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.50 |
| Max. Negotiated Rate |
$45.10 |
| Rate for Payer: Aetna Commercial |
$11.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$45.10
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Cash Price |
$22.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$11.70
|
| Rate for Payer: Multiplan PHCS |
$27.06
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.57
|
| Rate for Payer: UHCCP Medicaid |
$15.78
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
OP
|
$4,681.55
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$4,494.29 |
| Rate for Payer: Aetna Commercial |
$3,604.79
|
| Rate for Payer: Anthem Medicaid |
$1,609.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,651.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.89
|
| Rate for Payer: Cash Price |
$2,340.78
|
| Rate for Payer: Cash Price |
$2,340.78
|
| Rate for Payer: Cigna Commercial |
$3,885.69
|
| Rate for Payer: First Health Commercial |
$4,447.47
|
| Rate for Payer: Humana Commercial |
$3,979.32
|
| Rate for Payer: Humana KY Medicaid |
$1,609.99
|
| Rate for Payer: Humana Medicare Advantage |
$8.80
|
| Rate for Payer: Kentucky WC Medicaid |
$1,626.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,838.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,454.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,642.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,119.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,511.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,451.28
|
| Rate for Payer: PHCS Commercial |
$4,494.29
|
| Rate for Payer: United Healthcare All Payer |
$4,119.76
|
|
|
DYSPORT 5u (500u SDV)
|
Facility
|
IP
|
$4,681.55
|
|
|
Service Code
|
HCPCS J0586
|
| Hospital Charge Code |
25004363
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$608.60 |
| Max. Negotiated Rate |
$4,494.29 |
| Rate for Payer: Aetna Commercial |
$3,604.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,651.61
|
| Rate for Payer: Cash Price |
$2,340.78
|
| Rate for Payer: Cigna Commercial |
$3,885.69
|
| Rate for Payer: First Health Commercial |
$4,447.47
|
| Rate for Payer: Humana Commercial |
$3,979.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,838.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,454.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,404.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,119.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,511.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$936.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$608.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,451.28
|
| Rate for Payer: PHCS Commercial |
$4,494.29
|
| Rate for Payer: United Healthcare All Payer |
$4,119.76
|
|
|
DYSPORT - AP
|
Professional
|
Both
|
$3.34
|
|
| Hospital Charge Code |
22200369
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$3.34 |
| Rate for Payer: Buckeye Medicare Advantage |
$3.34
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Multiplan PHCS |
$2.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2.34
|
| Rate for Payer: UHCCP Medicaid |
$1.17
|
|
|
EACH ADD. BRONCHIAL STENT
|
Professional
|
Both
|
$161.00
|
|
|
Service Code
|
HCPCS 31637
|
| Hospital Charge Code |
41000047
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$135.11
|
| Rate for Payer: Anthem Medicaid |
$64.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.00
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cigna Commercial |
$123.57
|
| Rate for Payer: Healthspan PPO |
$105.49
|
| Rate for Payer: Humana Medicaid |
$64.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.82
|
| Rate for Payer: Molina Healthcare Passport |
$64.53
|
| Rate for Payer: Multiplan PHCS |
$96.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.70
|
| Rate for Payer: UHCCP Medicaid |
$56.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.18
|
|
|
EACH ADD. BRONCHIAL STENT(P
|
Professional
|
Both
|
$161.00
|
|
|
Service Code
|
HCPCS 31637
|
| Hospital Charge Code |
410P0047
|
|
Hospital Revenue Code
|
410
|
| Min. Negotiated Rate |
$56.35 |
| Max. Negotiated Rate |
$161.00 |
| Rate for Payer: Aetna Commercial |
$135.11
|
| Rate for Payer: Anthem Medicaid |
$64.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$161.00
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: Cigna Commercial |
$123.57
|
| Rate for Payer: Healthspan PPO |
$105.49
|
| Rate for Payer: Humana Medicaid |
$64.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$98.95
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.82
|
| Rate for Payer: Molina Healthcare Passport |
$64.53
|
| Rate for Payer: Multiplan PHCS |
$96.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$112.70
|
| Rate for Payer: UHCCP Medicaid |
$56.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$65.18
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
OP
|
$3,583.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
76100179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$465.79 |
| Max. Negotiated Rate |
$3,439.68 |
| Rate for Payer: Aetna Commercial |
$2,758.91
|
| Rate for Payer: Anthem Medicaid |
$1,232.19
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,794.74
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,791.50
|
| Rate for Payer: Cash Price |
$1,791.50
|
| Rate for Payer: Cigna Commercial |
$2,973.89
|
| Rate for Payer: First Health Commercial |
$3,403.85
|
| Rate for Payer: Humana Commercial |
$3,045.55
|
| Rate for Payer: Humana KY Medicaid |
$1,232.19
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,244.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,938.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,644.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,256.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,153.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,687.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$716.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$465.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,110.73
|
| Rate for Payer: PHCS Commercial |
$3,439.68
|
| Rate for Payer: United Healthcare All Payer |
$3,153.04
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
OP
|
$2,423.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
761T0179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.99 |
| Max. Negotiated Rate |
$2,326.08 |
| Rate for Payer: Aetna Commercial |
$1,865.71
|
| Rate for Payer: Anthem Medicaid |
$833.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,889.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cigna Commercial |
$2,011.09
|
| Rate for Payer: First Health Commercial |
$2,301.85
|
| Rate for Payer: Humana Commercial |
$2,059.55
|
| Rate for Payer: Humana KY Medicaid |
$833.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$841.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,986.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,788.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$849.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,132.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,817.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$484.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.13
|
| Rate for Payer: PHCS Commercial |
$2,326.08
|
| Rate for Payer: United Healthcare All Payer |
$2,132.24
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Professional
|
Both
|
$1,160.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
761P0179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$414.37 |
| Max. Negotiated Rate |
$1,160.00 |
| Rate for Payer: Aetna Commercial |
$1,095.02
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$414.37
|
| Rate for Payer: Anthem Medicaid |
$508.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,160.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cash Price |
$580.00
|
| Rate for Payer: Cigna Commercial |
$1,057.26
|
| Rate for Payer: Healthspan PPO |
$971.87
|
| Rate for Payer: Humana Medicaid |
$508.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$946.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$519.08
|
| Rate for Payer: Molina Healthcare Passport |
$508.90
|
| Rate for Payer: Multiplan PHCS |
$696.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$812.00
|
| Rate for Payer: UHCCP Medicaid |
$435.09
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$513.99
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Professional
|
Both
|
$3,583.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
76100179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$414.37 |
| Max. Negotiated Rate |
$3,583.00 |
| Rate for Payer: Aetna Commercial |
$1,095.02
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$414.37
|
| Rate for Payer: Anthem Medicaid |
$508.90
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,583.00
|
| Rate for Payer: Cash Price |
$1,791.50
|
| Rate for Payer: Cash Price |
$1,791.50
|
| Rate for Payer: Cigna Commercial |
$1,057.26
|
| Rate for Payer: Healthspan PPO |
$971.87
|
| Rate for Payer: Humana Medicaid |
$508.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$946.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$519.08
|
| Rate for Payer: Molina Healthcare Passport |
$508.90
|
| Rate for Payer: Multiplan PHCS |
$2,149.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,508.10
|
| Rate for Payer: UHCCP Medicaid |
$435.09
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$513.99
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
IP
|
$3,583.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
76100179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$465.79 |
| Max. Negotiated Rate |
$3,439.68 |
| Rate for Payer: Aetna Commercial |
$2,758.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,794.74
|
| Rate for Payer: Cash Price |
$1,791.50
|
| Rate for Payer: Cigna Commercial |
$2,973.89
|
| Rate for Payer: First Health Commercial |
$3,403.85
|
| Rate for Payer: Humana Commercial |
$3,045.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,938.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,644.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,074.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,153.04
|
| Rate for Payer: Ohio Health Group HMO |
$2,687.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$716.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$465.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,110.73
|
| Rate for Payer: PHCS Commercial |
$3,439.68
|
| Rate for Payer: United Healthcare All Payer |
$3,153.04
|
|
|
EA FACE/NK/HF/G 1SR 100SQCM <
|
Facility
|
IP
|
$2,423.00
|
|
|
Service Code
|
HCPCS 15115
|
| Hospital Charge Code |
761T0179
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.99 |
| Max. Negotiated Rate |
$2,326.08 |
| Rate for Payer: Aetna Commercial |
$1,865.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,889.94
|
| Rate for Payer: Cash Price |
$1,211.50
|
| Rate for Payer: Cigna Commercial |
$2,011.09
|
| Rate for Payer: First Health Commercial |
$2,301.85
|
| Rate for Payer: Humana Commercial |
$2,059.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,986.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,788.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$726.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,132.24
|
| Rate for Payer: Ohio Health Group HMO |
$1,817.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$484.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$314.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$751.13
|
| Rate for Payer: PHCS Commercial |
$2,326.08
|
| Rate for Payer: United Healthcare All Payer |
$2,132.24
|
|
|
EA FCE/NK/HF/G EA ADTL 100SQCM
|
Facility
|
OP
|
$1,095.00
|
|
|
Service Code
|
HCPCS 15116
|
| Hospital Charge Code |
76100180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.35 |
| Max. Negotiated Rate |
$1,051.20 |
| Rate for Payer: Aetna Commercial |
$843.15
|
| Rate for Payer: Anthem Medicaid |
$376.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$854.10
|
| Rate for Payer: Cash Price |
$547.50
|
| Rate for Payer: Cigna Commercial |
$908.85
|
| Rate for Payer: First Health Commercial |
$1,040.25
|
| Rate for Payer: Humana Commercial |
$930.75
|
| Rate for Payer: Humana KY Medicaid |
$376.57
|
| Rate for Payer: Kentucky WC Medicaid |
$380.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$897.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$808.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$328.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$384.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$963.60
|
| Rate for Payer: Ohio Health Group HMO |
$821.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$219.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.45
|
| Rate for Payer: PHCS Commercial |
$1,051.20
|
| Rate for Payer: United Healthcare All Payer |
$963.60
|
|
|
EA FCE/NK/HF/G EA ADTL 100SQCM
|
Facility
|
IP
|
$1,095.00
|
|
|
Service Code
|
HCPCS 15116
|
| Hospital Charge Code |
76100180
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$142.35 |
| Max. Negotiated Rate |
$1,051.20 |
| Rate for Payer: Aetna Commercial |
$843.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$854.10
|
| Rate for Payer: Cash Price |
$547.50
|
| Rate for Payer: Cigna Commercial |
$908.85
|
| Rate for Payer: First Health Commercial |
$1,040.25
|
| Rate for Payer: Humana Commercial |
$930.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$897.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$808.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$328.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$963.60
|
| Rate for Payer: Ohio Health Group HMO |
$821.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$219.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$339.45
|
| Rate for Payer: PHCS Commercial |
$1,051.20
|
| Rate for Payer: United Healthcare All Payer |
$963.60
|
|
|
EAGLE EYE PLATINUM
|
Facility
|
IP
|
$4,895.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$636.35 |
| Max. Negotiated Rate |
$4,699.20 |
| Rate for Payer: Aetna Commercial |
$3,769.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,818.10
|
| Rate for Payer: Cash Price |
$2,447.50
|
| Rate for Payer: Cigna Commercial |
$4,062.85
|
| Rate for Payer: First Health Commercial |
$4,650.25
|
| Rate for Payer: Humana Commercial |
$4,160.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,013.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,612.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,468.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,307.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,671.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$979.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$636.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,517.45
|
| Rate for Payer: PHCS Commercial |
$4,699.20
|
| Rate for Payer: United Healthcare All Payer |
$4,307.60
|
|
|
EAGLE EYE PLATINUM
|
Facility
|
OP
|
$4,895.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$636.35 |
| Max. Negotiated Rate |
$4,699.20 |
| Rate for Payer: Aetna Commercial |
$3,769.15
|
| Rate for Payer: Anthem Medicaid |
$1,683.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,818.10
|
| Rate for Payer: Cash Price |
$2,447.50
|
| Rate for Payer: Cigna Commercial |
$4,062.85
|
| Rate for Payer: First Health Commercial |
$4,650.25
|
| Rate for Payer: Humana Commercial |
$4,160.75
|
| Rate for Payer: Humana KY Medicaid |
$1,683.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,700.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,013.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,612.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,468.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,717.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,307.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,671.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$979.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$636.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,517.45
|
| Rate for Payer: PHCS Commercial |
$4,699.20
|
| Rate for Payer: United Healthcare All Payer |
$4,307.60
|
|
