|
FAMILY THERAPY
|
Professional
|
Both
|
$453.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
90000010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$67.71 |
| Max. Negotiated Rate |
$271.80 |
| Rate for Payer: Aetna Commercial |
$161.69
|
| Rate for Payer: Ambetter Exchange |
$101.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.71
|
| Rate for Payer: Anthem Medicaid |
$78.65
|
| Rate for Payer: Buckeye Individual/Medicaid |
$101.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$101.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$121.85
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$142.98
|
| Rate for Payer: Healthspan PPO |
$130.54
|
| Rate for Payer: Humana Medicaid |
$78.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$112.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$101.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$80.22
|
| Rate for Payer: Molina Healthcare Passport |
$78.65
|
| Rate for Payer: Multiplan PHCS |
$271.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$132.00
|
| Rate for Payer: UHCCP Medicaid |
$71.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$79.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$101.54
|
|
|
FAMILY THERAPY
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
90000010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$434.88 |
| Rate for Payer: Aetna Commercial |
$348.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$353.34
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$375.99
|
| Rate for Payer: First Health Commercial |
$430.35
|
| Rate for Payer: Humana Commercial |
$385.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$371.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$334.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$398.64
|
| Rate for Payer: Ohio Health Group HMO |
$339.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$394.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.57
|
| Rate for Payer: PHCS Commercial |
$434.88
|
| Rate for Payer: United Healthcare All Payer |
$398.64
|
|
|
FAMILY THERAPY
|
Facility
|
OP
|
$453.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
90000010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$148.46 |
| Max. Negotiated Rate |
$434.88 |
| Rate for Payer: Aetna Commercial |
$348.81
|
| Rate for Payer: Anthem Medicaid |
$155.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$148.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$353.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$207.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$200.42
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$375.99
|
| Rate for Payer: First Health Commercial |
$430.35
|
| Rate for Payer: Humana Commercial |
$385.05
|
| Rate for Payer: Humana KY Medicaid |
$155.79
|
| Rate for Payer: Humana Medicare Advantage |
$148.46
|
| Rate for Payer: Kentucky WC Medicaid |
$157.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$371.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$334.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$158.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$398.64
|
| Rate for Payer: Ohio Health Group HMO |
$339.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$394.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.57
|
| Rate for Payer: PHCS Commercial |
$434.88
|
| Rate for Payer: United Healthcare All Payer |
$398.64
|
|
|
FAMILY THERAPY(P
|
Professional
|
Both
|
$153.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
900P0010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$67.71 |
| Max. Negotiated Rate |
$161.69 |
| Rate for Payer: Aetna Commercial |
$161.69
|
| Rate for Payer: Ambetter Exchange |
$101.54
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$67.71
|
| Rate for Payer: Anthem Medicaid |
$78.65
|
| Rate for Payer: Buckeye Individual/Medicaid |
$101.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$101.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$121.85
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cash Price |
$76.50
|
| Rate for Payer: Cigna Commercial |
$142.98
|
| Rate for Payer: Healthspan PPO |
$130.54
|
| Rate for Payer: Humana Medicaid |
$78.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$112.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$101.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$101.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$80.22
|
| Rate for Payer: Molina Healthcare Passport |
$78.65
|
| Rate for Payer: Multiplan PHCS |
$91.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$132.00
|
| Rate for Payer: UHCCP Medicaid |
$71.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$79.44
|
| Rate for Payer: Wellcare Medicare Advantage |
$101.54
|
|
|
FAMILY THERAPY(T
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
900T0010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$103.17 |
| 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 |
$148.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$207.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$200.42
|
| 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 |
$148.46
|
| 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 |
$178.15
|
| 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 |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
FAMILY THERAPY(T
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 90847
|
| Hospital Charge Code |
900T0010
|
|
Hospital Revenue Code
|
900
|
| Min. Negotiated Rate |
$90.00 |
| Max. Negotiated Rate |
$288.00 |
| Rate for Payer: Aetna Commercial |
$231.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.00
|
| 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: 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 |
$90.00
|
| 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 |
$240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$261.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$207.00
|
| Rate for Payer: PHCS Commercial |
$288.00
|
| Rate for Payer: United Healthcare All Payer |
$264.00
|
|
|
FAMOTIDINE(0.25MG)200MG/20ML
|
Facility
|
OP
|
$115.79
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
25003820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$111.16 |
| Rate for Payer: Aetna Commercial |
$89.16
|
| Rate for Payer: Anthem Medicaid |
$39.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$96.11
|
| Rate for Payer: First Health Commercial |
$110.00
|
| Rate for Payer: Humana Commercial |
$98.42
|
| Rate for Payer: Humana KY Medicaid |
$39.82
|
| Rate for Payer: Kentucky WC Medicaid |
$40.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.90
|
| Rate for Payer: Ohio Health Group HMO |
$86.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.90
|
| Rate for Payer: PHCS Commercial |
$111.16
|
| Rate for Payer: United Healthcare All Payer |
$101.90
|
|
|
FAMOTIDINE(0.25MG)200MG/20ML
|
Facility
|
IP
|
$115.79
|
|
|
Service Code
|
HCPCS J1308
|
| Hospital Charge Code |
25003820
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.74 |
| Max. Negotiated Rate |
$111.16 |
| Rate for Payer: Aetna Commercial |
$89.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.32
|
| Rate for Payer: Cash Price |
$57.90
|
| Rate for Payer: Cigna Commercial |
$96.11
|
| Rate for Payer: First Health Commercial |
$110.00
|
| Rate for Payer: Humana Commercial |
$98.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.90
|
| Rate for Payer: Ohio Health Group HMO |
$86.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$79.90
|
| Rate for Payer: PHCS Commercial |
$111.16
|
| Rate for Payer: United Healthcare All Payer |
$101.90
|
|
|
FAMOTIDINE 40MG/5ML SUSP
|
Facility
|
OP
|
$5.19
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
25004228
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.56 |
| 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 |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| 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 |
$1.56 |
| 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 |
$4.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.58
|
| Rate for Payer: PHCS Commercial |
$4.98
|
| Rate for Payer: United Healthcare All Payer |
$4.57
|
|
|
FAN LIME 10X30 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X30 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X32 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X32 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X34 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X34 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X36 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X36 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X38 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X38 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X40 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X40 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X42 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X42 LF
|
Facility
|
IP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
|
FAN LIME 10X44 LF
|
Facility
|
OP
|
$9,930.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,979.19 |
| Max. Negotiated Rate |
$9,533.40 |
| Rate for Payer: Aetna Commercial |
$7,646.58
|
| Rate for Payer: Anthem Medicaid |
$3,415.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,745.88
|
| Rate for Payer: Cash Price |
$4,965.31
|
| Rate for Payer: Cigna Commercial |
$8,242.41
|
| Rate for Payer: First Health Commercial |
$9,434.09
|
| Rate for Payer: Humana Commercial |
$8,441.03
|
| Rate for Payer: Humana KY Medicaid |
$3,415.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,449.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,143.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,328.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,979.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,483.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,738.95
|
| Rate for Payer: Ohio Health Group HMO |
$7,447.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,944.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,639.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,852.13
|
| Rate for Payer: PHCS Commercial |
$9,533.40
|
| Rate for Payer: United Healthcare All Payer |
$8,738.95
|
|
