|
DIST FEM AUG BLOCK #9/15MM
|
Facility
|
IP
|
$4,901.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,470.30 |
| Max. Negotiated Rate |
$4,704.96 |
| Rate for Payer: Aetna Commercial |
$3,773.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,822.78
|
| Rate for Payer: Cash Price |
$2,450.50
|
| Rate for Payer: Cigna Commercial |
$4,067.83
|
| Rate for Payer: First Health Commercial |
$4,655.95
|
| Rate for Payer: Humana Commercial |
$4,165.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,018.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,616.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,470.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,312.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,675.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,920.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,263.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,381.69
|
| Rate for Payer: PHCS Commercial |
$4,704.96
|
| Rate for Payer: United Healthcare All Payer |
$4,312.88
|
|
|
DIST FEM AUG BLOCK #9/15MM
|
Facility
|
OP
|
$4,901.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,470.30 |
| Max. Negotiated Rate |
$4,704.96 |
| Rate for Payer: Aetna Commercial |
$3,773.77
|
| Rate for Payer: Anthem Medicaid |
$1,685.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,822.78
|
| Rate for Payer: Cash Price |
$2,450.50
|
| Rate for Payer: Cigna Commercial |
$4,067.83
|
| Rate for Payer: First Health Commercial |
$4,655.95
|
| Rate for Payer: Humana Commercial |
$4,165.85
|
| Rate for Payer: Humana KY Medicaid |
$1,685.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,702.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,018.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,616.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,470.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,719.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,312.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,675.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,920.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,263.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,381.69
|
| Rate for Payer: PHCS Commercial |
$4,704.96
|
| Rate for Payer: United Healthcare All Payer |
$4,312.88
|
|
|
DIST REVAS LIGATION HEMO
|
Professional
|
Both
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
76101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$1,880.95 |
| Rate for Payer: Aetna Commercial |
$1,880.95
|
| Rate for Payer: Ambetter Exchange |
$1,070.60
|
| Rate for Payer: Anthem Medicaid |
$909.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,070.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,070.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,284.72
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,803.52
|
| Rate for Payer: Healthspan PPO |
$1,503.99
|
| Rate for Payer: Humana Medicaid |
$909.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,565.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,070.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,070.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$927.34
|
| Rate for Payer: Molina Healthcare Passport |
$909.16
|
| Rate for Payer: Multiplan PHCS |
$1,068.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,391.78
|
| Rate for Payer: UHCCP Medicaid |
$623.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$918.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,070.60
|
|
|
DIST REVAS LIGATION HEMO
|
Facility
|
OP
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
76101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$612.14 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Aetna Commercial |
$1,370.60
|
| Rate for Payer: Anthem Medicaid |
$612.14
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,388.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,477.40
|
| Rate for Payer: First Health Commercial |
$1,691.00
|
| Rate for Payer: Humana Commercial |
$1,513.00
|
| Rate for Payer: Humana KY Medicaid |
$612.14
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Kentucky WC Medicaid |
$618.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,459.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,313.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$624.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,566.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,335.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,424.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,548.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.20
|
| Rate for Payer: PHCS Commercial |
$1,708.80
|
| Rate for Payer: United Healthcare All Payer |
$1,566.40
|
|
|
DIST REVAS LIGATION HEMO
|
Facility
|
IP
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
76101513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$534.00 |
| Max. Negotiated Rate |
$1,708.80 |
| Rate for Payer: Aetna Commercial |
$1,370.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,388.40
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,477.40
|
| Rate for Payer: First Health Commercial |
$1,691.00
|
| Rate for Payer: Humana Commercial |
$1,513.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,459.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,313.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$534.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,566.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,335.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,424.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,548.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,228.20
|
| Rate for Payer: PHCS Commercial |
$1,708.80
|
| Rate for Payer: United Healthcare All Payer |
$1,566.40
|
|
|
DIST REVAS LIGATION HEMO(P
|
Professional
|
Both
|
$1,780.00
|
|
|
Service Code
|
HCPCS 36838
|
| Hospital Charge Code |
761P1513
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$623.00 |
| Max. Negotiated Rate |
$1,880.95 |
| Rate for Payer: Aetna Commercial |
$1,880.95
|
| Rate for Payer: Ambetter Exchange |
$1,070.60
|
| Rate for Payer: Anthem Medicaid |
$909.16
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,070.60
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,070.60
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,284.72
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cash Price |
$890.00
|
| Rate for Payer: Cigna Commercial |
$1,803.52
|
| Rate for Payer: Healthspan PPO |
$1,503.99
|
| Rate for Payer: Humana Medicaid |
$909.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,565.19
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,070.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,070.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$927.34
|
| Rate for Payer: Molina Healthcare Passport |
$909.16
|
| Rate for Payer: Multiplan PHCS |
$1,068.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,391.78
|
| Rate for Payer: UHCCP Medicaid |
$623.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$918.25
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,070.60
|
|
|
DISULFIRAM 250 MG TABLET
|
Facility
|
OP
|
$10.83
|
|
|
Service Code
|
NDC 47781060730
|
| Hospital Charge Code |
25003986
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna Commercial |
$8.34
|
| Rate for Payer: Anthem Medicaid |
$3.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.45
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cigna Commercial |
$8.99
|
| Rate for Payer: First Health Commercial |
$10.29
|
| Rate for Payer: Humana Commercial |
$9.21
|
| Rate for Payer: Humana KY Medicaid |
$3.72
|
| Rate for Payer: Kentucky WC Medicaid |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.53
|
| Rate for Payer: Ohio Health Group HMO |
$8.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.47
|
| Rate for Payer: PHCS Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Payer |
$9.53
|
|
|
DISULFIRAM 250 MG TABLET
|
Facility
|
IP
|
$10.83
|
|
|
Service Code
|
NDC 47781060730
|
| Hospital Charge Code |
25003986
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$10.40 |
| Rate for Payer: Aetna Commercial |
$8.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.45
|
| Rate for Payer: Cash Price |
$5.42
|
| Rate for Payer: Cigna Commercial |
$8.99
|
| Rate for Payer: First Health Commercial |
$10.29
|
| Rate for Payer: Humana Commercial |
$9.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.53
|
| Rate for Payer: Ohio Health Group HMO |
$8.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.47
|
| Rate for Payer: PHCS Commercial |
$10.40
|
| Rate for Payer: United Healthcare All Payer |
$9.53
|
|
|
DITROPAN (OXYBUTYNIN) 5MG/1TAB
|
Facility
|
OP
|
$4.66
|
|
|
Service Code
|
NDC 60687067001
|
| Hospital Charge Code |
25000573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Anthem Medicaid |
$1.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: First Health Commercial |
$4.43
|
| Rate for Payer: Humana Commercial |
$3.96
|
| Rate for Payer: Humana KY Medicaid |
$1.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.10
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
|
DITROPAN (OXYBUTYNIN) 5MG/1TAB
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 60687067001
|
| Hospital Charge Code |
25000573
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna Commercial |
$3.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna Commercial |
$3.87
|
| Rate for Payer: First Health Commercial |
$4.43
|
| Rate for Payer: Humana Commercial |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.10
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.22
|
| Rate for Payer: PHCS Commercial |
$4.47
|
| Rate for Payer: United Healthcare All Payer |
$4.10
|
|
|
DITROPAN XL (OXYBUTYNIN) 5MG T
|
Facility
|
IP
|
$10.57
|
|
|
Service Code
|
NDC 68084048001
|
| Hospital Charge Code |
25000574
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$8.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Cash Price |
$5.28
|
| Rate for Payer: Cigna Commercial |
$8.77
|
| Rate for Payer: First Health Commercial |
$10.04
|
| Rate for Payer: Humana Commercial |
$8.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.29
|
| Rate for Payer: PHCS Commercial |
$10.15
|
| Rate for Payer: United Healthcare All Payer |
$9.30
|
|
|
DITROPAN XL (OXYBUTYNIN) 5MG T
|
Facility
|
OP
|
$10.57
|
|
|
Service Code
|
NDC 68084048001
|
| Hospital Charge Code |
25000574
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.17 |
| Max. Negotiated Rate |
$10.15 |
| Rate for Payer: Aetna Commercial |
$8.14
|
| Rate for Payer: Anthem Medicaid |
$3.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.24
|
| Rate for Payer: Cash Price |
$5.28
|
| Rate for Payer: Cigna Commercial |
$8.77
|
| Rate for Payer: First Health Commercial |
$10.04
|
| Rate for Payer: Humana Commercial |
$8.98
|
| Rate for Payer: Humana KY Medicaid |
$3.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.30
|
| Rate for Payer: Ohio Health Group HMO |
$7.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.29
|
| Rate for Payer: PHCS Commercial |
$10.15
|
| Rate for Payer: United Healthcare All Payer |
$9.30
|
|
|
DIURIL (CHLOROTHIA 500MG/1VIAL
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
HCPCS J1205
|
| Hospital Charge Code |
25002035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$315.84 |
| Rate for Payer: Aetna Commercial |
$253.33
|
| Rate for Payer: Anthem Medicaid |
$113.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.62
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$273.07
|
| Rate for Payer: First Health Commercial |
$312.55
|
| Rate for Payer: Humana Commercial |
$279.65
|
| Rate for Payer: Humana KY Medicaid |
$113.14
|
| Rate for Payer: Kentucky WC Medicaid |
$114.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.52
|
| Rate for Payer: Ohio Health Group HMO |
$246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.01
|
| Rate for Payer: PHCS Commercial |
$315.84
|
| Rate for Payer: United Healthcare All Payer |
$289.52
|
|
|
DIURIL (CHLOROTHIA 500MG/1VIAL
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
HCPCS J1205
|
| Hospital Charge Code |
25002035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$98.70 |
| Max. Negotiated Rate |
$315.84 |
| Rate for Payer: Aetna Commercial |
$253.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$256.62
|
| Rate for Payer: Cash Price |
$164.50
|
| Rate for Payer: Cigna Commercial |
$273.07
|
| Rate for Payer: First Health Commercial |
$312.55
|
| Rate for Payer: Humana Commercial |
$279.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$269.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$242.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$98.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$289.52
|
| Rate for Payer: Ohio Health Group HMO |
$246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$263.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.01
|
| Rate for Payer: PHCS Commercial |
$315.84
|
| Rate for Payer: United Healthcare All Payer |
$289.52
|
|
|
DLTA TS CER HED 12/14 28MM 8.5
|
Facility
|
OP
|
$11,147.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,344.26 |
| Max. Negotiated Rate |
$10,701.65 |
| Rate for Payer: Aetna Commercial |
$8,583.61
|
| Rate for Payer: Anthem Medicaid |
$3,833.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,695.09
|
| Rate for Payer: Cash Price |
$5,573.77
|
| Rate for Payer: Cigna Commercial |
$9,252.47
|
| Rate for Payer: First Health Commercial |
$10,590.17
|
| Rate for Payer: Humana Commercial |
$9,475.42
|
| Rate for Payer: Humana KY Medicaid |
$3,833.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3,872.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,140.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,226.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,344.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,910.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,809.84
|
| Rate for Payer: Ohio Health Group HMO |
$8,360.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,918.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,698.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,691.81
|
| Rate for Payer: PHCS Commercial |
$10,701.65
|
| Rate for Payer: United Healthcare All Payer |
$9,809.84
|
|
|
DLTA TS CER HED 12/14 28MM 8.5
|
Facility
|
IP
|
$11,147.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,344.26 |
| Max. Negotiated Rate |
$10,701.65 |
| Rate for Payer: Aetna Commercial |
$8,583.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,695.09
|
| Rate for Payer: Cash Price |
$5,573.77
|
| Rate for Payer: Cigna Commercial |
$9,252.47
|
| Rate for Payer: First Health Commercial |
$10,590.17
|
| Rate for Payer: Humana Commercial |
$9,475.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,140.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,226.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,344.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,809.84
|
| Rate for Payer: Ohio Health Group HMO |
$8,360.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,918.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,698.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,691.81
|
| Rate for Payer: PHCS Commercial |
$10,701.65
|
| Rate for Payer: United Healthcare All Payer |
$9,809.84
|
|
|
DLTA TS CER. HED 12/14 44MM 12
|
Facility
|
OP
|
$15,981.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,794.30 |
| Max. Negotiated Rate |
$15,341.76 |
| Rate for Payer: Aetna Commercial |
$12,305.37
|
| Rate for Payer: Anthem Medicaid |
$5,495.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,465.18
|
| Rate for Payer: Cash Price |
$7,990.50
|
| Rate for Payer: Cigna Commercial |
$13,264.23
|
| Rate for Payer: First Health Commercial |
$15,181.95
|
| Rate for Payer: Humana Commercial |
$13,583.85
|
| Rate for Payer: Humana KY Medicaid |
$5,495.87
|
| Rate for Payer: Kentucky WC Medicaid |
$5,551.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,104.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,793.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,794.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,606.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,063.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,985.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,784.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,903.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,026.89
|
| Rate for Payer: PHCS Commercial |
$15,341.76
|
| Rate for Payer: United Healthcare All Payer |
$14,063.28
|
|
|
DLTA TS CER. HED 12/14 44MM 12
|
Facility
|
IP
|
$15,981.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,794.30 |
| Max. Negotiated Rate |
$15,341.76 |
| Rate for Payer: Aetna Commercial |
$12,305.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,465.18
|
| Rate for Payer: Cash Price |
$7,990.50
|
| Rate for Payer: Cigna Commercial |
$13,264.23
|
| Rate for Payer: First Health Commercial |
$15,181.95
|
| Rate for Payer: Humana Commercial |
$13,583.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,104.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,793.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,794.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,063.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,985.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,784.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,903.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,026.89
|
| Rate for Payer: PHCS Commercial |
$15,341.76
|
| Rate for Payer: United Healthcare All Payer |
$14,063.28
|
|
|
DLTA TS CER HED 12/14 44MM+1.5
|
Facility
|
IP
|
$20,191.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,057.38 |
| Max. Negotiated Rate |
$19,383.60 |
| Rate for Payer: Aetna Commercial |
$15,547.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,749.17
|
| Rate for Payer: Cash Price |
$10,095.62
|
| Rate for Payer: Cigna Commercial |
$16,758.74
|
| Rate for Payer: First Health Commercial |
$19,181.69
|
| Rate for Payer: Humana Commercial |
$17,162.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,556.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,901.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,057.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,768.30
|
| Rate for Payer: Ohio Health Group HMO |
$15,143.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,153.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,566.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,931.96
|
| Rate for Payer: PHCS Commercial |
$19,383.60
|
| Rate for Payer: United Healthcare All Payer |
$17,768.30
|
|
|
DLTA TS CER HED 12/14 44MM+1.5
|
Facility
|
OP
|
$20,191.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,057.38 |
| Max. Negotiated Rate |
$19,383.60 |
| Rate for Payer: Aetna Commercial |
$15,547.26
|
| Rate for Payer: Anthem Medicaid |
$6,943.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,749.17
|
| Rate for Payer: Cash Price |
$10,095.62
|
| Rate for Payer: Cigna Commercial |
$16,758.74
|
| Rate for Payer: First Health Commercial |
$19,181.69
|
| Rate for Payer: Humana Commercial |
$17,162.56
|
| Rate for Payer: Humana KY Medicaid |
$6,943.77
|
| Rate for Payer: Kentucky WC Medicaid |
$7,014.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,556.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,901.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,057.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,083.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,768.30
|
| Rate for Payer: Ohio Health Group HMO |
$15,143.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,153.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,566.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,931.96
|
| Rate for Payer: PHCS Commercial |
$19,383.60
|
| Rate for Payer: United Healthcare All Payer |
$17,768.30
|
|
|
DLTA TS CER HED 12/14 44MM 8.5
|
Facility
|
IP
|
$15,981.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,794.30 |
| Max. Negotiated Rate |
$15,341.76 |
| Rate for Payer: Aetna Commercial |
$12,305.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,465.18
|
| Rate for Payer: Cash Price |
$7,990.50
|
| Rate for Payer: Cigna Commercial |
$13,264.23
|
| Rate for Payer: First Health Commercial |
$15,181.95
|
| Rate for Payer: Humana Commercial |
$13,583.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,104.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,793.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,794.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,063.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,985.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,784.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,903.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,026.89
|
| Rate for Payer: PHCS Commercial |
$15,341.76
|
| Rate for Payer: United Healthcare All Payer |
$14,063.28
|
|
|
DLTA TS CER HED 12/14 44MM 8.5
|
Facility
|
OP
|
$15,981.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,794.30 |
| Max. Negotiated Rate |
$15,341.76 |
| Rate for Payer: Aetna Commercial |
$12,305.37
|
| Rate for Payer: Anthem Medicaid |
$5,495.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,465.18
|
| Rate for Payer: Cash Price |
$7,990.50
|
| Rate for Payer: Cigna Commercial |
$13,264.23
|
| Rate for Payer: First Health Commercial |
$15,181.95
|
| Rate for Payer: Humana Commercial |
$13,583.85
|
| Rate for Payer: Humana KY Medicaid |
$5,495.87
|
| Rate for Payer: Kentucky WC Medicaid |
$5,551.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,104.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,793.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,794.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,606.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,063.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,985.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,784.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,903.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,026.89
|
| Rate for Payer: PHCS Commercial |
$15,341.76
|
| Rate for Payer: United Healthcare All Payer |
$14,063.28
|
|
|
DLYD PLMT XTN PROSTH 1ST VSL
|
Professional
|
Both
|
$2,256.00
|
|
|
Service Code
|
HCPCS 34710
|
| Hospital Charge Code |
76102656
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$643.15 |
| Max. Negotiated Rate |
$1,471.61 |
| Rate for Payer: Ambetter Exchange |
$745.16
|
| Rate for Payer: Anthem Medicaid |
$643.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$745.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$745.16
|
| Rate for Payer: CareSource Just4Me Medicare |
$894.19
|
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: Cash Price |
$1,128.00
|
| Rate for Payer: Cigna Commercial |
$1,471.61
|
| Rate for Payer: Humana Medicaid |
$643.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,072.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$745.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$745.16
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$656.01
|
| Rate for Payer: Molina Healthcare Passport |
$643.15
|
| Rate for Payer: Multiplan PHCS |
$1,353.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$968.71
|
| Rate for Payer: UHCCP Medicaid |
$789.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$649.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$745.16
|
|
|
DLYD PLMT XTN PROSTH EA ADDL
|
Professional
|
Both
|
$690.00
|
|
|
Service Code
|
HCPCS 34711
|
| Hospital Charge Code |
76103039
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.51 |
| Max. Negotiated Rate |
$550.08 |
| Rate for Payer: Ambetter Exchange |
$276.75
|
| Rate for Payer: Anthem Medicaid |
$240.51
|
| Rate for Payer: Buckeye Individual/Medicaid |
$276.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$276.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$332.10
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna Commercial |
$550.08
|
| Rate for Payer: Humana Medicaid |
$240.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$401.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$276.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$276.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$245.32
|
| Rate for Payer: Molina Healthcare Passport |
$240.51
|
| Rate for Payer: Multiplan PHCS |
$414.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$359.77
|
| Rate for Payer: UHCCP Medicaid |
$241.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$242.92
|
| Rate for Payer: Wellcare Medicare Advantage |
$276.75
|
|
|
DLY TREATMNT 2 AREAS 6-10 MEV
|
Facility
|
IP
|
$336.00
|
|
|
Service Code
|
HCPCS 77407
|
| Hospital Charge Code |
33300025
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$100.80 |
| Max. Negotiated Rate |
$322.56 |
| Rate for Payer: Aetna Commercial |
$258.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$262.08
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna Commercial |
$278.88
|
| Rate for Payer: First Health Commercial |
$319.20
|
| Rate for Payer: Humana Commercial |
$285.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$275.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$295.68
|
| Rate for Payer: Ohio Health Group HMO |
$252.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$268.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$292.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$231.84
|
| Rate for Payer: PHCS Commercial |
$322.56
|
| Rate for Payer: United Healthcare All Payer |
$295.68
|
|
