|
FAMILY THERAPY(T
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
900T0010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem Medicaid |
$103.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$137.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$193.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$186.12
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$249.00
|
| Rate for Payer: First Health Commercial |
$285.00
|
| Rate for Payer: Humana Commercial |
$255.00
|
| Rate for Payer: Humana KY Medicaid |
$103.17
|
| Rate for Payer: Humana Medicare Advantage |
$137.87
|
| Rate for Payer: Kentucky WC Medicaid |
$104.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$221.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.00
|
| Rate for Payer: Ohio Health Group HMO |
$225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
FAMOTIDINE 40MG/5ML SUSP
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
25004228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem Medicaid |
$1.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Humana KY Medicaid |
$1.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
FAMOTIDINE 40MG/5ML SUSP
|
Facility
|
IP
|
$5.19
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
25004228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.98 |
| Rate for Payer: Aetna Commercial |
$4.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: Cigna Commercial |
$4.31
|
| Rate for Payer: First Health Commercial |
$4.93
|
| Rate for Payer: Humana Commercial |
$4.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.57
|
| Rate for Payer: Ohio Health Group HMO |
$3.89
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.61
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
FAN LIME 10X30 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X30 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X32 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X32 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X34 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X34 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X36 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X36 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X38 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X38 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X40 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X40 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X42 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X42 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X44 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X44 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X46 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X46 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X48 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X48 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X50 LF
|
Facility
|
IP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
|
FAN LIME 10X50 LF
|
Facility
|
OP
|
$9,730.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,264.98 |
| Max. Negotiated Rate |
$9,341.40 |
| Rate for Payer: Aetna Commercial |
$7,492.58
|
| Rate for Payer: Anthem Medicaid |
$3,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,589.88
|
| Rate for Payer: Cash Price |
$4,865.31
|
| Rate for Payer: Cigna Commercial |
$8,076.41
|
| Rate for Payer: First Health Commercial |
$9,244.09
|
| Rate for Payer: Humana Commercial |
$8,271.03
|
| Rate for Payer: Humana KY Medicaid |
$3,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,380.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,979.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,181.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,919.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,413.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,562.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,297.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,946.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,264.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,016.49
|
| Rate for Payer: PHCS Commercial |
$9,341.40
|
| Rate for Payer: United Healthcare All Payer |
$8,562.95
|
|
