|
EXFOLIATE CLEANSER 200ML GBL
|
Professional
|
Both
|
$45.00
|
|
| Hospital Charge Code |
22200140
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$31.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
|
|
EXFOLIATE CLEANSER 200ML GBL
|
Facility
|
IP
|
$45.00
|
|
| Hospital Charge Code |
22200140
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna Commercial |
$34.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35.10
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cigna Commercial |
$37.35
|
| Rate for Payer: First Health Commercial |
$42.75
|
| Rate for Payer: Humana Commercial |
$38.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$39.60
|
| Rate for Payer: Ohio Health Group HMO |
$33.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.05
|
| Rate for Payer: PHCS Commercial |
$43.20
|
| Rate for Payer: United Healthcare All Payer |
$39.60
|
|
|
EXFOLIATING POLISH
|
Facility
|
OP
|
$67.00
|
|
| Hospital Charge Code |
22200161
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem Medicaid |
$23.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Humana KY Medicaid |
$23.04
|
| Rate for Payer: Kentucky WC Medicaid |
$23.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
EXFOLIATING POLISH
|
Facility
|
IP
|
$67.00
|
|
| Hospital Charge Code |
22200161
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$64.32 |
| Rate for Payer: Aetna Commercial |
$51.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.26
|
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Cigna Commercial |
$55.61
|
| Rate for Payer: First Health Commercial |
$63.65
|
| Rate for Payer: Humana Commercial |
$56.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.96
|
| Rate for Payer: Ohio Health Group HMO |
$50.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.23
|
| Rate for Payer: PHCS Commercial |
$64.32
|
| Rate for Payer: United Healthcare All Payer |
$58.96
|
|
|
EXFOLIATING POLISH
|
Professional
|
Both
|
$67.00
|
|
| Hospital Charge Code |
22200161
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$23.45 |
| Max. Negotiated Rate |
$46.90 |
| Rate for Payer: Cash Price |
$33.50
|
| Rate for Payer: Multiplan PHCS |
$40.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$46.90
|
| Rate for Payer: UHCCP Medicaid |
$23.45
|
|
|
EX FOR SPEECH DEVICE RX ADDL
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 92608
|
| Hospital Charge Code |
44000011
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
EX FOR SPEECH DEVICE RX ADDL
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 92608
|
| Hospital Charge Code |
44000011
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Facility
|
OP
|
$4,740.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
761T0896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,550.40 |
| Rate for Payer: Aetna Commercial |
$3,649.80
|
| Rate for Payer: Anthem Medicaid |
$1,630.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,697.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$2,370.00
|
| Rate for Payer: Cash Price |
$2,370.00
|
| Rate for Payer: Cigna Commercial |
$3,934.20
|
| Rate for Payer: First Health Commercial |
$4,503.00
|
| Rate for Payer: Humana Commercial |
$4,029.00
|
| Rate for Payer: Humana KY Medicaid |
$1,630.09
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,646.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,886.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,498.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,662.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,171.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,555.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,792.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,123.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,270.60
|
| Rate for Payer: PHCS Commercial |
$4,550.40
|
| Rate for Payer: United Healthcare All Payer |
$4,171.20
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
761P0896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.46 |
| Max. Negotiated Rate |
$622.06 |
| Rate for Payer: Aetna Commercial |
$556.72
|
| Rate for Payer: Ambetter Exchange |
$290.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$157.46
|
| Rate for Payer: Anthem Medicaid |
$209.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$290.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$349.02
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$600.07
|
| Rate for Payer: Healthspan PPO |
$622.06
|
| Rate for Payer: Humana Medicaid |
$209.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$392.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$290.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$290.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.24
|
| Rate for Payer: Molina Healthcare Passport |
$209.06
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$378.11
|
| Rate for Payer: UHCCP Medicaid |
$165.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$290.85
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Facility
|
IP
|
$5,740.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
76100896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,722.00 |
| Max. Negotiated Rate |
$5,510.40 |
| Rate for Payer: Aetna Commercial |
$4,419.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,477.20
|
| Rate for Payer: Cash Price |
$2,870.00
|
| Rate for Payer: Cigna Commercial |
$4,764.20
|
| Rate for Payer: First Health Commercial |
$5,453.00
|
| Rate for Payer: Humana Commercial |
$4,879.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,706.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,236.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,722.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,305.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,592.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,993.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,960.60
|
| Rate for Payer: PHCS Commercial |
$5,510.40
|
| Rate for Payer: United Healthcare All Payer |
$5,051.20
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Facility
|
IP
|
$4,740.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
761T0896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,422.00 |
| Max. Negotiated Rate |
$4,550.40 |
| Rate for Payer: Aetna Commercial |
$3,649.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,697.20
|
| Rate for Payer: Cash Price |
$2,370.00
|
| Rate for Payer: Cigna Commercial |
$3,934.20
|
| Rate for Payer: First Health Commercial |
$4,503.00
|
| Rate for Payer: Humana Commercial |
$4,029.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,886.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,498.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,422.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,171.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,555.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,792.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,123.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,270.60
|
| Rate for Payer: PHCS Commercial |
$4,550.40
|
| Rate for Payer: United Healthcare All Payer |
$4,171.20
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Professional
|
Both
|
$5,740.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
76100896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.46 |
| Max. Negotiated Rate |
$3,444.00 |
| Rate for Payer: Aetna Commercial |
$556.72
|
| Rate for Payer: Ambetter Exchange |
$290.85
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$157.46
|
| Rate for Payer: Anthem Medicaid |
$209.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$290.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$290.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$349.02
|
| Rate for Payer: Cash Price |
$2,870.00
|
| Rate for Payer: Cash Price |
$2,870.00
|
| Rate for Payer: Cigna Commercial |
$600.07
|
| Rate for Payer: Healthspan PPO |
$622.06
|
| Rate for Payer: Humana Medicaid |
$209.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$392.17
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$290.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$290.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.24
|
| Rate for Payer: Molina Healthcare Passport |
$209.06
|
| Rate for Payer: Multiplan PHCS |
$3,444.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$378.11
|
| Rate for Payer: UHCCP Medicaid |
$165.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.15
|
| Rate for Payer: Wellcare Medicare Advantage |
$290.85
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Facility
|
OP
|
$5,740.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
76100896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$5,510.40 |
| Rate for Payer: Aetna Commercial |
$4,419.80
|
| Rate for Payer: Anthem Medicaid |
$1,973.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,477.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$2,870.00
|
| Rate for Payer: Cash Price |
$2,870.00
|
| Rate for Payer: Cigna Commercial |
$4,764.20
|
| Rate for Payer: First Health Commercial |
$5,453.00
|
| Rate for Payer: Humana Commercial |
$4,879.00
|
| Rate for Payer: Humana KY Medicaid |
$1,973.99
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,994.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,706.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,236.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,013.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,051.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,305.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,592.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,993.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,960.60
|
| Rate for Payer: PHCS Commercial |
$5,510.40
|
| Rate for Payer: United Healthcare All Payer |
$5,051.20
|
|
|
EXJADE 250MG TAB
|
Facility
|
IP
|
$272.89
|
|
|
Service Code
|
NDC 78046915
|
| Hospital Charge Code |
25000653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.87 |
| Max. Negotiated Rate |
$261.97 |
| Rate for Payer: Aetna Commercial |
$210.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$212.85
|
| Rate for Payer: Cash Price |
$136.44
|
| Rate for Payer: Cigna Commercial |
$226.50
|
| Rate for Payer: First Health Commercial |
$259.25
|
| Rate for Payer: Humana Commercial |
$231.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$223.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$201.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$240.14
|
| Rate for Payer: Ohio Health Group HMO |
$204.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$218.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$237.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$188.29
|
| Rate for Payer: PHCS Commercial |
$261.97
|
| Rate for Payer: United Healthcare All Payer |
$240.14
|
|
|
EXJADE 250MG TAB
|
Facility
|
OP
|
$272.89
|
|
|
Service Code
|
NDC 78046915
|
| Hospital Charge Code |
25000653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.87 |
| Max. Negotiated Rate |
$261.97 |
| Rate for Payer: Aetna Commercial |
$210.13
|
| Rate for Payer: Anthem Medicaid |
$93.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$212.85
|
| Rate for Payer: Cash Price |
$136.44
|
| Rate for Payer: Cigna Commercial |
$226.50
|
| Rate for Payer: First Health Commercial |
$259.25
|
| Rate for Payer: Humana Commercial |
$231.96
|
| Rate for Payer: Humana KY Medicaid |
$93.85
|
| Rate for Payer: Kentucky WC Medicaid |
$94.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$223.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$201.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$95.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$240.14
|
| Rate for Payer: Ohio Health Group HMO |
$204.67
|
| Rate for Payer: Ohio Health Group PPO Differential |
$218.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$237.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$188.29
|
| Rate for Payer: PHCS Commercial |
$261.97
|
| Rate for Payer: United Healthcare All Payer |
$240.14
|
|
|
EXPANDER ALLOX FH SMTH 360-430
|
Facility
|
OP
|
$7,361.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,208.53 |
| Max. Negotiated Rate |
$7,067.28 |
| Rate for Payer: Aetna Commercial |
$5,668.55
|
| Rate for Payer: Anthem Medicaid |
$2,531.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.16
|
| Rate for Payer: Cash Price |
$3,680.88
|
| Rate for Payer: Cigna Commercial |
$6,110.25
|
| Rate for Payer: First Health Commercial |
$6,993.66
|
| Rate for Payer: Humana Commercial |
$6,257.49
|
| Rate for Payer: Humana KY Medicaid |
$2,531.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,036.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,432.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,478.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,889.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,404.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,079.61
|
| Rate for Payer: PHCS Commercial |
$7,067.28
|
| Rate for Payer: United Healthcare All Payer |
$6,478.34
|
|
|
EXPANDER ALLOX FH SMTH 360-430
|
Facility
|
IP
|
$7,361.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,208.53 |
| Max. Negotiated Rate |
$7,067.28 |
| Rate for Payer: Aetna Commercial |
$5,668.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.16
|
| Rate for Payer: Cash Price |
$3,680.88
|
| Rate for Payer: Cigna Commercial |
$6,110.25
|
| Rate for Payer: First Health Commercial |
$6,993.66
|
| Rate for Payer: Humana Commercial |
$6,257.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,036.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,432.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,478.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,889.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,404.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,079.61
|
| Rate for Payer: PHCS Commercial |
$7,067.28
|
| Rate for Payer: United Healthcare All Payer |
$6,478.34
|
|
|
EXPANDER ALLOX FH SMTH 480-575
|
Facility
|
OP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem Medicaid |
$3,535.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Humana KY Medicaid |
$3,535.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3,571.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,606.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX FH SMTH 480-575
|
Facility
|
IP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX FH SMTH 600-720
|
Facility
|
OP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem Medicaid |
$3,535.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Humana KY Medicaid |
$3,535.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3,571.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,606.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX FH SMTH 600-720
|
Facility
|
IP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX FH SMTH 750-900
|
Facility
|
OP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem Medicaid |
$3,535.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Humana KY Medicaid |
$3,535.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3,571.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,606.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX FH SMTH 750-900
|
Facility
|
IP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX MD SMTH 225-280
|
Facility
|
IP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
|
EXPANDER ALLOX MD SMTH 225-280
|
Facility
|
OP
|
$10,281.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,084.53 |
| Max. Negotiated Rate |
$9,870.48 |
| Rate for Payer: Aetna Commercial |
$7,916.95
|
| Rate for Payer: Anthem Medicaid |
$3,535.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,019.77
|
| Rate for Payer: Cash Price |
$5,140.88
|
| Rate for Payer: Cigna Commercial |
$8,533.85
|
| Rate for Payer: First Health Commercial |
$9,767.66
|
| Rate for Payer: Humana Commercial |
$8,739.49
|
| Rate for Payer: Humana KY Medicaid |
$3,535.89
|
| Rate for Payer: Kentucky WC Medicaid |
$3,571.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,431.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,587.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,084.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,606.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,047.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,711.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,225.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,945.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,094.41
|
| Rate for Payer: PHCS Commercial |
$9,870.48
|
| Rate for Payer: United Healthcare All Payer |
$9,047.94
|
|
