|
EVENITY 105MG SYRINGES (2)
|
Facility
|
OP
|
$14,327.61
|
|
|
Service Code
|
HCPCS J3111
|
| Hospital Charge Code |
25003722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$13,754.51 |
| Rate for Payer: Aetna Commercial |
$11,032.26
|
| Rate for Payer: Anthem Medicaid |
$4,927.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,175.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$16.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.20
|
| Rate for Payer: Cash Price |
$7,163.80
|
| Rate for Payer: Cash Price |
$7,163.80
|
| Rate for Payer: Cigna Commercial |
$11,891.92
|
| Rate for Payer: First Health Commercial |
$13,611.23
|
| Rate for Payer: Humana Commercial |
$12,178.47
|
| Rate for Payer: Humana KY Medicaid |
$4,927.27
|
| Rate for Payer: Humana Medicare Advantage |
$12.00
|
| Rate for Payer: Kentucky WC Medicaid |
$4,977.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,748.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,573.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,026.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,608.30
|
| Rate for Payer: Ohio Health Group HMO |
$10,745.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,462.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,465.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,886.05
|
| Rate for Payer: PHCS Commercial |
$13,754.51
|
| Rate for Payer: United Healthcare All Payer |
$12,608.30
|
|
|
EVENITY 105MG SYRINGES (2)
|
Facility
|
IP
|
$14,327.61
|
|
|
Service Code
|
HCPCS J3111
|
| Hospital Charge Code |
25003722
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,298.28 |
| Max. Negotiated Rate |
$13,754.51 |
| Rate for Payer: Aetna Commercial |
$11,032.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,175.54
|
| Rate for Payer: Cash Price |
$7,163.80
|
| Rate for Payer: Cigna Commercial |
$11,891.92
|
| Rate for Payer: First Health Commercial |
$13,611.23
|
| Rate for Payer: Humana Commercial |
$12,178.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,748.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,573.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,298.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,608.30
|
| Rate for Payer: Ohio Health Group HMO |
$10,745.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,462.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,465.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,886.05
|
| Rate for Payer: PHCS Commercial |
$13,754.51
|
| Rate for Payer: United Healthcare All Payer |
$12,608.30
|
|
|
EVENT RECORDER SUP/INT ONLY
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 93272
|
| Hospital Charge Code |
48000076
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.50 |
| 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 |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.35
|
| 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 |
$34.50 |
| 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 |
$92.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.35
|
| 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 |
$22.50 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$45.38
|
| Rate for Payer: Ambetter Exchange |
$22.50
|
| Rate for Payer: Anthem Medicaid |
$27.20
|
| Rate for Payer: Buckeye Individual/Medicaid |
$22.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$22.50
|
| Rate for Payer: CareSource Just4Me Medicare |
$27.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$22.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| 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 |
$29.25
|
| Rate for Payer: UHCCP Medicaid |
$40.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$27.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$22.50
|
|
|
EVERCROS .035 OTWPTA 10*20*135
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTWPTA 10*20*135
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 10*20*80
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 10*20*80
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 10*40*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROS .035 OTW PTA 10*40*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROS .035 OTW PTA 10*60*80
|
Facility
|
IP
|
$3,293.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$988.12 |
| Max. Negotiated Rate |
$3,162.00 |
| Rate for Payer: Aetna Commercial |
$2,536.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,569.12
|
| Rate for Payer: Cash Price |
$1,646.88
|
| Rate for Payer: Cigna Commercial |
$2,733.81
|
| Rate for Payer: First Health Commercial |
$3,129.06
|
| Rate for Payer: Humana Commercial |
$2,799.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,700.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,430.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$988.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,898.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,470.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,865.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,272.69
|
| Rate for Payer: PHCS Commercial |
$3,162.00
|
| Rate for Payer: United Healthcare All Payer |
$2,898.50
|
|
|
EVERCROS .035 OTW PTA 10*60*80
|
Facility
|
OP
|
$3,293.75
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$988.12 |
| Max. Negotiated Rate |
$3,162.00 |
| Rate for Payer: Aetna Commercial |
$2,536.19
|
| Rate for Payer: Anthem Medicaid |
$1,132.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,569.12
|
| Rate for Payer: Cash Price |
$1,646.88
|
| Rate for Payer: Cigna Commercial |
$2,733.81
|
| Rate for Payer: First Health Commercial |
$3,129.06
|
| Rate for Payer: Humana Commercial |
$2,799.69
|
| Rate for Payer: Humana KY Medicaid |
$1,132.72
|
| Rate for Payer: Kentucky WC Medicaid |
$1,144.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,700.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,430.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$988.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,155.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,898.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,470.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,635.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,865.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,272.69
|
| Rate for Payer: PHCS Commercial |
$3,162.00
|
| Rate for Payer: United Healthcare All Payer |
$2,898.50
|
|
|
EVERCROS .035 OTWPTA 12*20*135
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTWPTA 12*20*135
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 12*20*80
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 12*20*80
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 12*40*80
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 12*40*80
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 12*60*80
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTW PTA 12*60*80
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROS .035 OTWPTA 3*100*135
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROS .035 OTWPTA 3*100*135
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROS .035 OTWPTA 3*150*135
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
EVERCROS .035 OTWPTA 3*150*135
|
Facility
|
IP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
