|
DIALYSIS PROCEDURE(T
|
Facility
|
OP
|
$1,310.20
|
|
|
Service Code
|
HCPCS 90999
|
| Hospital Charge Code |
880T0003
|
|
Hospital Revenue Code
|
880
|
| Min. Negotiated Rate |
$393.06 |
| Max. Negotiated Rate |
$1,257.79 |
| Rate for Payer: Aetna Commercial |
$1,008.85
|
| Rate for Payer: Anthem Medicaid |
$450.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,021.96
|
| Rate for Payer: Cash Price |
$655.10
|
| Rate for Payer: Cigna Commercial |
$1,087.47
|
| Rate for Payer: First Health Commercial |
$1,244.69
|
| Rate for Payer: Humana Commercial |
$1,113.67
|
| Rate for Payer: Humana KY Medicaid |
$450.58
|
| Rate for Payer: Kentucky WC Medicaid |
$455.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,074.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$966.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$393.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$459.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,152.98
|
| Rate for Payer: Ohio Health Group HMO |
$982.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,048.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,139.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$904.04
|
| Rate for Payer: PHCS Commercial |
$1,257.79
|
| Rate for Payer: United Healthcare All Payer |
$1,152.98
|
|
|
DIALYSIS REPEATED EVAL
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 90947
|
| Hospital Charge Code |
76103013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$175.72
|
| Rate for Payer: Ambetter Exchange |
$114.89
|
| Rate for Payer: Anthem Medicaid |
$122.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.87
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$148.12
|
| Rate for Payer: Healthspan PPO |
$143.80
|
| Rate for Payer: Humana Medicaid |
$122.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.30
|
| Rate for Payer: Molina Healthcare Passport |
$122.84
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.36
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.89
|
|
|
DIALYSIS REPEATED EVAL (P
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 90947
|
| Hospital Charge Code |
761P3013
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$175.72
|
| Rate for Payer: Ambetter Exchange |
$114.89
|
| Rate for Payer: Anthem Medicaid |
$122.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$114.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$114.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$137.87
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$148.12
|
| Rate for Payer: Healthspan PPO |
$143.80
|
| Rate for Payer: Humana Medicaid |
$122.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$162.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$114.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.30
|
| Rate for Payer: Molina Healthcare Passport |
$122.84
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$149.36
|
| Rate for Payer: UHCCP Medicaid |
$105.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$114.89
|
|
|
DIAMONDBACK 1.25*145
|
Facility
|
IP
|
$16,961.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,088.45 |
| Max. Negotiated Rate |
$16,283.04 |
| Rate for Payer: Aetna Commercial |
$13,060.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,229.97
|
| Rate for Payer: Cash Price |
$8,480.75
|
| Rate for Payer: Cigna Commercial |
$14,078.05
|
| Rate for Payer: First Health Commercial |
$16,113.42
|
| Rate for Payer: Humana Commercial |
$14,417.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,908.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,517.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,088.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,926.12
|
| Rate for Payer: Ohio Health Group HMO |
$12,721.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,569.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,756.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,703.43
|
| Rate for Payer: PHCS Commercial |
$16,283.04
|
| Rate for Payer: United Healthcare All Payer |
$14,926.12
|
|
|
DIAMONDBACK 1.25*145
|
Facility
|
OP
|
$16,961.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,088.45 |
| Max. Negotiated Rate |
$16,283.04 |
| Rate for Payer: Aetna Commercial |
$13,060.35
|
| Rate for Payer: Anthem Medicaid |
$5,833.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,229.97
|
| Rate for Payer: Cash Price |
$8,480.75
|
| Rate for Payer: Cigna Commercial |
$14,078.05
|
| Rate for Payer: First Health Commercial |
$16,113.42
|
| Rate for Payer: Humana Commercial |
$14,417.27
|
| Rate for Payer: Humana KY Medicaid |
$5,833.06
|
| Rate for Payer: Kentucky WC Medicaid |
$5,892.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,908.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,517.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,088.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,950.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,926.12
|
| Rate for Payer: Ohio Health Group HMO |
$12,721.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,569.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,756.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,703.43
|
| Rate for Payer: PHCS Commercial |
$16,283.04
|
| Rate for Payer: United Healthcare All Payer |
$14,926.12
|
|
|
DIAMONDBACK 1.25*60
|
Facility
|
OP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem Medicaid |
$6,342.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Humana KY Medicaid |
$6,342.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,406.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,469.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DIAMONDBACK 1.25*60
|
Facility
|
IP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DIAMONDBACK 360 CLASSIC 1.25
|
Facility
|
IP
|
$19,181.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,754.45 |
| Max. Negotiated Rate |
$18,414.24 |
| Rate for Payer: Aetna Commercial |
$14,769.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,961.57
|
| Rate for Payer: Cash Price |
$9,590.75
|
| Rate for Payer: Cigna Commercial |
$15,920.65
|
| Rate for Payer: First Health Commercial |
$18,222.42
|
| Rate for Payer: Humana Commercial |
$16,304.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,728.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,155.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,754.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,879.72
|
| Rate for Payer: Ohio Health Group HMO |
$14,386.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,345.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,687.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,235.24
|
| Rate for Payer: PHCS Commercial |
$18,414.24
|
| Rate for Payer: United Healthcare All Payer |
$16,879.72
|
|
|
DIAMONDBACK 360 CLASSIC 1.25
|
Facility
|
OP
|
$19,181.50
|
|
|
Service Code
|
HCPCS C1724
|
| Hospital Charge Code |
27000007
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,754.45 |
| Max. Negotiated Rate |
$18,414.24 |
| Rate for Payer: Aetna Commercial |
$14,769.75
|
| Rate for Payer: Anthem Medicaid |
$6,596.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,961.57
|
| Rate for Payer: Cash Price |
$9,590.75
|
| Rate for Payer: Cigna Commercial |
$15,920.65
|
| Rate for Payer: First Health Commercial |
$18,222.42
|
| Rate for Payer: Humana Commercial |
$16,304.27
|
| Rate for Payer: Humana KY Medicaid |
$6,596.52
|
| Rate for Payer: Kentucky WC Medicaid |
$6,663.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,728.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,155.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,754.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,728.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,879.72
|
| Rate for Payer: Ohio Health Group HMO |
$14,386.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,345.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,687.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,235.24
|
| Rate for Payer: PHCS Commercial |
$18,414.24
|
| Rate for Payer: United Healthcare All Payer |
$16,879.72
|
|
|
DIAMOX (ACETAZOLAMI 250MG/1TAB
|
Facility
|
OP
|
$4.55
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
25000551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.14
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
DIAMOX (ACETAZOLAMI 250MG/1TAB
|
Facility
|
IP
|
$4.55
|
|
|
Service Code
|
NDC 51672402301
|
| Hospital Charge Code |
25000551
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.37 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.55
|
| Rate for Payer: Cash Price |
$2.28
|
| Rate for Payer: Cigna Commercial |
$3.78
|
| Rate for Payer: First Health Commercial |
$4.32
|
| Rate for Payer: Humana Commercial |
$3.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.14
|
| Rate for Payer: PHCS Commercial |
$4.37
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
DIAMOX (ACETAZOLAMID 500MG/5ML
|
Facility
|
IP
|
$199.96
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
25002019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.99 |
| Max. Negotiated Rate |
$191.96 |
| Rate for Payer: Aetna Commercial |
$153.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.97
|
| Rate for Payer: Cash Price |
$99.98
|
| Rate for Payer: Cigna Commercial |
$165.97
|
| Rate for Payer: First Health Commercial |
$189.96
|
| Rate for Payer: Humana Commercial |
$169.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.96
|
| Rate for Payer: Ohio Health Group HMO |
$149.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.97
|
| Rate for Payer: PHCS Commercial |
$191.96
|
| Rate for Payer: United Healthcare All Payer |
$175.96
|
|
|
DIAMOX (ACETAZOLAMID 500MG/5ML
|
Facility
|
OP
|
$199.96
|
|
|
Service Code
|
HCPCS J1120
|
| Hospital Charge Code |
25002019
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.99 |
| Max. Negotiated Rate |
$191.96 |
| Rate for Payer: Aetna Commercial |
$153.97
|
| Rate for Payer: Anthem Medicaid |
$68.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.97
|
| Rate for Payer: Cash Price |
$99.98
|
| Rate for Payer: Cigna Commercial |
$165.97
|
| Rate for Payer: First Health Commercial |
$189.96
|
| Rate for Payer: Humana Commercial |
$169.97
|
| Rate for Payer: Humana KY Medicaid |
$68.77
|
| Rate for Payer: Kentucky WC Medicaid |
$69.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.96
|
| Rate for Payer: Ohio Health Group HMO |
$149.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.97
|
| Rate for Payer: PHCS Commercial |
$191.96
|
| Rate for Payer: United Healthcare All Payer |
$175.96
|
|
|
DIANEAL PD1.5D Mg0.53.5Ca 2.5L
|
Facility
|
OP
|
$27.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004374
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$26.69 |
| Rate for Payer: Aetna Commercial |
$21.41
|
| Rate for Payer: Anthem Medicaid |
$9.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.68
|
| Rate for Payer: Cash Price |
$13.90
|
| Rate for Payer: Cigna Commercial |
$23.07
|
| Rate for Payer: First Health Commercial |
$26.41
|
| Rate for Payer: Humana Commercial |
$23.63
|
| Rate for Payer: Humana KY Medicaid |
$9.56
|
| Rate for Payer: Kentucky WC Medicaid |
$9.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.46
|
| Rate for Payer: Ohio Health Group HMO |
$20.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.18
|
| Rate for Payer: PHCS Commercial |
$26.69
|
| Rate for Payer: United Healthcare All Payer |
$24.46
|
|
|
DIANEAL PD1.5D Mg0.53.5Ca 2.5L
|
Facility
|
IP
|
$27.80
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004374
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$8.34 |
| Max. Negotiated Rate |
$26.69 |
| Rate for Payer: Aetna Commercial |
$21.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.68
|
| Rate for Payer: Cash Price |
$13.90
|
| Rate for Payer: Cigna Commercial |
$23.07
|
| Rate for Payer: First Health Commercial |
$26.41
|
| Rate for Payer: Humana Commercial |
$23.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.46
|
| Rate for Payer: Ohio Health Group HMO |
$20.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.18
|
| Rate for Payer: PHCS Commercial |
$26.69
|
| Rate for Payer: United Healthcare All Payer |
$24.46
|
|
|
DIAPHYSEAL ELLIP OSS SEG 3CM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$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
|
|
|
DIAPHYSEAL ELLIP OSS SEG 3CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 11CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 11CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 13CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 13CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 15CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 15CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 17CM
|
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
|
|
|
DIAPHYSEAL OSS SEG 17CM
|
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
|
|
