|
EVASC RPR A-BIILIAC RPT(P
|
Professional
|
Both
|
$2,575.00
|
|
|
Service Code
|
HCPCS 34706
|
| Hospital Charge Code |
761P1348
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$901.25 |
| Max. Negotiated Rate |
$4,233.07 |
| Rate for Payer: Anthem Medicaid |
$1,851.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,575.00
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cash Price |
$1,287.50
|
| Rate for Payer: Cigna Commercial |
$4,233.07
|
| Rate for Payer: Humana Medicaid |
$1,851.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,088.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,888.07
|
| Rate for Payer: Molina Healthcare Passport |
$1,851.05
|
| Rate for Payer: Multiplan PHCS |
$1,545.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,802.50
|
| Rate for Payer: UHCCP Medicaid |
$901.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,869.56
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Facility
|
OP
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
76102609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$211.90 |
| Max. Negotiated Rate |
$1,564.80 |
| Rate for Payer: Aetna Commercial |
$1,255.10
|
| Rate for Payer: Anthem Medicaid |
$560.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,271.40
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$1,352.90
|
| Rate for Payer: First Health Commercial |
$1,548.50
|
| Rate for Payer: Humana Commercial |
$1,385.50
|
| Rate for Payer: Humana KY Medicaid |
$560.56
|
| Rate for Payer: Kentucky WC Medicaid |
$566.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,336.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,202.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$571.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,434.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$326.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$211.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$505.30
|
| Rate for Payer: PHCS Commercial |
$1,564.80
|
| Rate for Payer: United Healthcare All Payer |
$1,434.40
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Professional
|
Both
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
761P2609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$2,550.74 |
| Rate for Payer: Anthem Medicaid |
$1,114.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,630.00
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$2,550.74
|
| Rate for Payer: Humana Medicaid |
$1,114.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,861.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,136.39
|
| Rate for Payer: Molina Healthcare Passport |
$1,114.11
|
| Rate for Payer: Multiplan PHCS |
$978.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,141.00
|
| Rate for Payer: UHCCP Medicaid |
$570.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,125.25
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Facility
|
IP
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
76102609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$211.90 |
| Max. Negotiated Rate |
$1,564.80 |
| Rate for Payer: Aetna Commercial |
$1,255.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,271.40
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$1,352.90
|
| Rate for Payer: First Health Commercial |
$1,548.50
|
| Rate for Payer: Humana Commercial |
$1,385.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,336.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,202.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$489.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,434.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$326.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$211.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$505.30
|
| Rate for Payer: PHCS Commercial |
$1,564.80
|
| Rate for Payer: United Healthcare All Payer |
$1,434.40
|
|
|
EVASC RPR A-UNILAC NDGFT
|
Professional
|
Both
|
$1,630.00
|
|
|
Service Code
|
HCPCS 34703
|
| Hospital Charge Code |
76102609
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$570.50 |
| Max. Negotiated Rate |
$2,550.74 |
| Rate for Payer: Anthem Medicaid |
$1,114.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,630.00
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cash Price |
$815.00
|
| Rate for Payer: Cigna Commercial |
$2,550.74
|
| Rate for Payer: Humana Medicaid |
$1,114.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,861.48
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,136.39
|
| Rate for Payer: Molina Healthcare Passport |
$1,114.11
|
| Rate for Payer: Multiplan PHCS |
$978.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,141.00
|
| Rate for Payer: UHCCP Medicaid |
$570.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,125.25
|
|
|
EVASC RPR ILIO-ILIAC NDGFT
|
Professional
|
Both
|
$1,205.00
|
|
|
Service Code
|
HCPCS 34707
|
| Hospital Charge Code |
76102744
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.75 |
| Max. Negotiated Rate |
$2,111.83 |
| Rate for Payer: Anthem Medicaid |
$923.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,205.00
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cash Price |
$602.50
|
| Rate for Payer: Cigna Commercial |
$2,111.83
|
| Rate for Payer: Humana Medicaid |
$923.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,540.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$941.98
|
| Rate for Payer: Molina Healthcare Passport |
$923.51
|
| Rate for Payer: Multiplan PHCS |
$723.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$843.50
|
| Rate for Payer: UHCCP Medicaid |
$421.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$932.75
|
|
|
EVASC RPR N/A A-ILIAC NDGFT
|
Professional
|
Both
|
$1,450.00
|
|
|
Service Code
|
HCPCS 34718
|
| Hospital Charge Code |
76102727
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$507.50 |
| Max. Negotiated Rate |
$1,740.55 |
| Rate for Payer: Anthem Medicaid |
$1,006.21
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,450.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Cash Price |
$725.00
|
| Rate for Payer: Humana Medicaid |
$1,006.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,740.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,026.33
|
| Rate for Payer: Molina Healthcare Passport |
$1,006.21
|
| Rate for Payer: Multiplan PHCS |
$870.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,015.00
|
| Rate for Payer: UHCCP Medicaid |
$507.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,016.27
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
OP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
76102515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$3,858.95 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem Medicaid |
$1,364.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Humana KY Medicaid |
$1,364.94
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$793.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,230.39
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
IP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
48100082
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$3,810.24 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$793.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,230.39
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
IP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
76102515
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$3,810.24 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$793.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,230.39
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EV CATH DIR CHEM ABLTJ W/IMG
|
Facility
|
OP
|
$3,969.00
|
|
|
Service Code
|
HCPCS 0524T
|
| Hospital Charge Code |
48100082
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$515.97 |
| Max. Negotiated Rate |
$3,858.95 |
| Rate for Payer: Aetna Commercial |
$3,056.13
|
| Rate for Payer: Anthem Medicaid |
$1,364.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,095.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cash Price |
$1,984.50
|
| Rate for Payer: Cigna Commercial |
$3,294.27
|
| Rate for Payer: First Health Commercial |
$3,770.55
|
| Rate for Payer: Humana Commercial |
$3,373.65
|
| Rate for Payer: Humana KY Medicaid |
$1,364.94
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,254.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,929.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,392.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,492.72
|
| Rate for Payer: Ohio Health Group HMO |
$2,976.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$793.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$515.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,230.39
|
| Rate for Payer: PHCS Commercial |
$3,810.24
|
| Rate for Payer: United Healthcare All Payer |
$3,492.72
|
|
|
EVENITY 105MG SYRINGES (2)
|
Facility
|
IP
|
$13,645.38
|
|
|
Service Code
|
HCPCS J3111
|
| Hospital Charge Code |
25003722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,773.90 |
| Max. Negotiated Rate |
$13,099.56 |
| Rate for Payer: Aetna Commercial |
$10,506.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,643.40
|
| Rate for Payer: Cash Price |
$6,822.69
|
| Rate for Payer: Cigna Commercial |
$11,325.67
|
| Rate for Payer: First Health Commercial |
$12,963.11
|
| Rate for Payer: Humana Commercial |
$11,598.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,189.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,070.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,093.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,007.93
|
| Rate for Payer: Ohio Health Group HMO |
$10,234.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,773.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,230.07
|
| Rate for Payer: PHCS Commercial |
$13,099.56
|
| Rate for Payer: United Healthcare All Payer |
$12,007.93
|
|
|
EVENITY 105MG SYRINGES (2)
|
Facility
|
OP
|
$13,645.38
|
|
|
Service Code
|
HCPCS J3111
|
| Hospital Charge Code |
25003722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.73 |
| Max. Negotiated Rate |
$13,099.56 |
| Rate for Payer: Aetna Commercial |
$10,506.94
|
| Rate for Payer: Anthem Medicaid |
$4,692.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,643.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$15.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$14.48
|
| Rate for Payer: Cash Price |
$6,822.69
|
| Rate for Payer: Cash Price |
$6,822.69
|
| Rate for Payer: Cigna Commercial |
$11,325.67
|
| Rate for Payer: First Health Commercial |
$12,963.11
|
| Rate for Payer: Humana Commercial |
$11,598.57
|
| Rate for Payer: Humana KY Medicaid |
$4,692.65
|
| Rate for Payer: Humana Medicare Advantage |
$10.73
|
| Rate for Payer: Kentucky WC Medicaid |
$4,740.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,189.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,070.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,786.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,007.93
|
| Rate for Payer: Ohio Health Group HMO |
$10,234.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,773.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,230.07
|
| Rate for Payer: PHCS Commercial |
$13,099.56
|
| Rate for Payer: United Healthcare All Payer |
$12,007.93
|
|
|
EVENT RECORDER SUP/INT ONLY
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 93272
|
| Hospital Charge Code |
48000076
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
EVENT RECORDER SUP/INT ONLY
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 93272
|
| Hospital Charge Code |
48000076
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$14.95 |
| Max. Negotiated Rate |
$110.40 |
| Rate for Payer: Aetna Commercial |
$88.55
|
| Rate for Payer: Anthem Medicaid |
$39.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.70
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$95.45
|
| Rate for Payer: First Health Commercial |
$109.25
|
| Rate for Payer: Humana Commercial |
$97.75
|
| Rate for Payer: Humana KY Medicaid |
$39.55
|
| Rate for Payer: Kentucky WC Medicaid |
$39.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.20
|
| Rate for Payer: Ohio Health Group HMO |
$86.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.65
|
| Rate for Payer: PHCS Commercial |
$110.40
|
| Rate for Payer: United Healthcare All Payer |
$101.20
|
|
|
EVENT RECORDER SUP/INT ONLY
|
Professional
|
Both
|
$115.00
|
|
|
Service Code
|
HCPCS 93272
|
| Hospital Charge Code |
48000076
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna Commercial |
$45.38
|
| Rate for Payer: Anthem Medicaid |
$27.20
|
| Rate for Payer: Buckeye Medicare Advantage |
$115.00
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cash Price |
$57.50
|
| Rate for Payer: Cigna Commercial |
$41.64
|
| Rate for Payer: Healthspan PPO |
$42.66
|
| Rate for Payer: Humana Medicaid |
$27.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$27.74
|
| Rate for Payer: Molina Healthcare Passport |
$27.20
|
| Rate for Payer: Multiplan PHCS |
$69.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$80.50
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.47
|
|
|
EVERCROS .035 OTWPTA 10*20*135
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
EVERCROS .035 OTWPTA 10*20*135
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem Medicaid |
$584.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Humana KY Medicaid |
$584.63
|
| Rate for Payer: Kentucky WC Medicaid |
$590.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$596.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
EVERCROS .035 OTW PTA 10*20*80
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem Medicaid |
$584.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Humana KY Medicaid |
$584.63
|
| Rate for Payer: Kentucky WC Medicaid |
$590.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$596.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
EVERCROS .035 OTW PTA 10*20*80
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
EVERCROS .035 OTW PTA 10*40*80
|
Facility
|
IP
|
$3,407.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$442.98 |
| Max. Negotiated Rate |
$3,271.20 |
| Rate for Payer: Aetna Commercial |
$2,623.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,657.85
|
| Rate for Payer: Cash Price |
$1,703.75
|
| Rate for Payer: Cigna Commercial |
$2,828.22
|
| Rate for Payer: First Health Commercial |
$3,237.12
|
| Rate for Payer: Humana Commercial |
$2,896.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,794.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,514.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,022.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,998.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$681.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,056.32
|
| Rate for Payer: PHCS Commercial |
$3,271.20
|
| Rate for Payer: United Healthcare All Payer |
$2,998.60
|
|
|
EVERCROS .035 OTW PTA 10*40*80
|
Facility
|
OP
|
$3,407.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$442.98 |
| Max. Negotiated Rate |
$3,271.20 |
| Rate for Payer: Aetna Commercial |
$2,623.78
|
| Rate for Payer: Anthem Medicaid |
$1,171.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,657.85
|
| Rate for Payer: Cash Price |
$1,703.75
|
| Rate for Payer: Cigna Commercial |
$2,828.22
|
| Rate for Payer: First Health Commercial |
$3,237.12
|
| Rate for Payer: Humana Commercial |
$2,896.38
|
| Rate for Payer: Humana KY Medicaid |
$1,171.84
|
| Rate for Payer: Kentucky WC Medicaid |
$1,183.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,794.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,514.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,022.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,195.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,998.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$681.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$442.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,056.32
|
| Rate for Payer: PHCS Commercial |
$3,271.20
|
| Rate for Payer: United Healthcare All Payer |
$2,998.60
|
|
|
EVERCROS .035 OTW PTA 10*60*80
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
|
|
EVERCROS .035 OTW PTA 10*60*80
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem Medicaid |
$584.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Humana KY Medicaid |
$584.63
|
| Rate for Payer: Kentucky WC Medicaid |
$590.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$596.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
EVERCROS .035 OTWPTA 12*20*135
|
Facility
|
OP
|
$1,700.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$221.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem Medicaid |
$584.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Humana KY Medicaid |
$584.63
|
| Rate for Payer: Kentucky WC Medicaid |
$590.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$596.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$527.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
