|
GAVISCON (COMBINATION) CH 1TAB
|
Facility
|
IP
|
$4.24
|
|
|
Service Code
|
NDC 904536560
|
| Hospital Charge Code |
25000713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
GAVISCON (COMBINATION) CH 1TAB
|
Facility
|
OP
|
$4.24
|
|
|
Service Code
|
NDC 904536560
|
| Hospital Charge Code |
25000713
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna Commercial |
$3.26
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.52
|
| Rate for Payer: First Health Commercial |
$4.03
|
| Rate for Payer: Humana Commercial |
$3.60
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.73
|
| Rate for Payer: Ohio Health Group HMO |
$3.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.07
|
| Rate for Payer: United Healthcare All Payer |
$3.73
|
|
|
GAZYVA 10MG [1000 MG VL]
|
Facility
|
OP
|
$44,918.03
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
25002667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.34 |
| Max. Negotiated Rate |
$43,121.31 |
| Rate for Payer: Aetna Commercial |
$34,586.88
|
| Rate for Payer: Anthem Medicaid |
$15,447.31
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$70.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35,036.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$98.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$94.96
|
| Rate for Payer: Cash Price |
$22,459.02
|
| Rate for Payer: Cash Price |
$22,459.02
|
| Rate for Payer: Cigna Commercial |
$37,281.96
|
| Rate for Payer: First Health Commercial |
$42,672.13
|
| Rate for Payer: Humana Commercial |
$38,180.33
|
| Rate for Payer: Humana KY Medicaid |
$15,447.31
|
| Rate for Payer: Humana Medicare Advantage |
$70.34
|
| Rate for Payer: Kentucky WC Medicaid |
$15,604.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,832.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33,149.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,757.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$39,527.87
|
| Rate for Payer: Ohio Health Group HMO |
$33,688.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,983.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,839.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,924.59
|
| Rate for Payer: PHCS Commercial |
$43,121.31
|
| Rate for Payer: United Healthcare All Payer |
$39,527.87
|
|
|
GAZYVA 10MG [1000 MG VL]
|
Facility
|
IP
|
$44,918.03
|
|
|
Service Code
|
HCPCS J9301
|
| Hospital Charge Code |
25002667
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,839.34 |
| Max. Negotiated Rate |
$43,121.31 |
| Rate for Payer: Aetna Commercial |
$34,586.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$35,036.06
|
| Rate for Payer: Cash Price |
$22,459.02
|
| Rate for Payer: Cigna Commercial |
$37,281.96
|
| Rate for Payer: First Health Commercial |
$42,672.13
|
| Rate for Payer: Humana Commercial |
$38,180.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$36,832.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$33,149.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,475.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$39,527.87
|
| Rate for Payer: Ohio Health Group HMO |
$33,688.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,983.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,839.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,924.59
|
| Rate for Payer: PHCS Commercial |
$43,121.31
|
| Rate for Payer: United Healthcare All Payer |
$39,527.87
|
|
|
GBS ENRICHMENT
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001271
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.30
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
GBS ENRICHMENT
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001271
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$7.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$9.22
|
| Rate for Payer: Healthspan PPO |
$6.95
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$3.98
|
|
|
GBS ENRICHMENT
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 87081
|
| Hospital Charge Code |
30001271
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$6.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$80.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9.28
|
| Rate for Payer: CareSource Just4Me Medicare |
$6.63
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$6.63
|
| Rate for Payer: Humana Medicare Advantage |
$6.63
|
| Rate for Payer: Kentucky WC Medicaid |
$6.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
GB ULTRASOUND ONLY LTD
|
Facility
|
OP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200022
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem Medicaid |
$379.67
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Humana KY Medicaid |
$379.67
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$383.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$387.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
GB ULTRASOUND ONLY LTD
|
Facility
|
IP
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200022
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$143.52 |
| Max. Negotiated Rate |
$1,059.84 |
| Rate for Payer: Aetna Commercial |
$850.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$861.12
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$916.32
|
| Rate for Payer: First Health Commercial |
$1,048.80
|
| Rate for Payer: Humana Commercial |
$938.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$905.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$814.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$331.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$971.52
|
| Rate for Payer: Ohio Health Group HMO |
$828.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$342.24
|
| Rate for Payer: PHCS Commercial |
$1,059.84
|
| Rate for Payer: United Healthcare All Payer |
$971.52
|
|
|
GB ULTRASOUND ONLY LTD
|
Professional
|
Both
|
$1,104.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
40200022
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,104.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cash Price |
$552.00
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$662.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$772.80
|
| Rate for Payer: UHCCP Medicaid |
$386.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
GB ULTRASOUND ONLY LTD(P
|
Professional
|
Both
|
$125.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402P0022
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$37.18 |
| Max. Negotiated Rate |
$157.49 |
| Rate for Payer: Aetna Commercial |
$157.49
|
| Rate for Payer: Anthem Medicaid |
$63.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$125.00
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cash Price |
$62.50
|
| Rate for Payer: Cigna Commercial |
$135.13
|
| Rate for Payer: Healthspan PPO |
$147.57
|
| Rate for Payer: Humana Medicaid |
$63.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$37.18
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.20
|
| Rate for Payer: Molina Healthcare Passport |
$63.92
|
| Rate for Payer: Multiplan PHCS |
$75.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$87.50
|
| Rate for Payer: UHCCP Medicaid |
$43.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.56
|
|
|
GB ULTRASOUND ONLY LTD(T
|
Facility
|
IP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0022
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$127.27 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$293.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
GB ULTRASOUND ONLY LTD(T
|
Facility
|
OP
|
$979.00
|
|
|
Service Code
|
HCPCS 76705
|
| Hospital Charge Code |
402T0022
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$95.07 |
| Max. Negotiated Rate |
$939.84 |
| Rate for Payer: Aetna Commercial |
$753.83
|
| Rate for Payer: Anthem Medicaid |
$336.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$95.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$763.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$133.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$128.34
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cash Price |
$489.50
|
| Rate for Payer: Cigna Commercial |
$812.57
|
| Rate for Payer: First Health Commercial |
$930.05
|
| Rate for Payer: Humana Commercial |
$832.15
|
| Rate for Payer: Humana KY Medicaid |
$336.68
|
| Rate for Payer: Humana Medicare Advantage |
$95.07
|
| Rate for Payer: Kentucky WC Medicaid |
$340.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$802.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$722.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$343.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$861.52
|
| Rate for Payer: Ohio Health Group HMO |
$734.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.49
|
| Rate for Payer: PHCS Commercial |
$939.84
|
| Rate for Payer: United Healthcare All Payer |
$861.52
|
|
|
GC 3DRC 6F 100CM
|
Facility
|
IP
|
$816.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.08 |
| Max. Negotiated Rate |
$783.36 |
| Rate for Payer: Aetna Commercial |
$628.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cigna Commercial |
$677.28
|
| Rate for Payer: First Health Commercial |
$775.20
|
| Rate for Payer: Humana Commercial |
$693.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$669.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$602.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$718.08
|
| Rate for Payer: Ohio Health Group HMO |
$612.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.96
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
|
|
GC 3DRC 6F 100CM
|
Facility
|
OP
|
$816.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.08 |
| Max. Negotiated Rate |
$783.36 |
| Rate for Payer: Aetna Commercial |
$628.32
|
| Rate for Payer: Anthem Medicaid |
$280.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.48
|
| Rate for Payer: Cash Price |
$408.00
|
| Rate for Payer: Cigna Commercial |
$677.28
|
| Rate for Payer: First Health Commercial |
$775.20
|
| Rate for Payer: Humana Commercial |
$693.60
|
| Rate for Payer: Humana KY Medicaid |
$280.62
|
| Rate for Payer: Kentucky WC Medicaid |
$283.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$669.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$602.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$286.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$718.08
|
| Rate for Payer: Ohio Health Group HMO |
$612.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.96
|
| Rate for Payer: PHCS Commercial |
$783.36
|
| Rate for Payer: United Healthcare All Payer |
$718.08
|
|
|
GC 6FR RDC I 55CM
|
Facility
|
OP
|
$1,755.65
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$228.23 |
| Max. Negotiated Rate |
$1,685.42 |
| Rate for Payer: Aetna Commercial |
$1,351.85
|
| Rate for Payer: Anthem Medicaid |
$603.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.41
|
| Rate for Payer: Cash Price |
$877.82
|
| Rate for Payer: Cigna Commercial |
$1,457.19
|
| Rate for Payer: First Health Commercial |
$1,667.87
|
| Rate for Payer: Humana Commercial |
$1,492.30
|
| Rate for Payer: Humana KY Medicaid |
$603.77
|
| Rate for Payer: Kentucky WC Medicaid |
$609.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$615.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,544.97
|
| Rate for Payer: Ohio Health Group HMO |
$1,316.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$351.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.25
|
| Rate for Payer: PHCS Commercial |
$1,685.42
|
| Rate for Payer: United Healthcare All Payer |
$1,544.97
|
|
|
GC 6FR RDC I 55CM
|
Facility
|
IP
|
$1,755.65
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$228.23 |
| Max. Negotiated Rate |
$1,685.42 |
| Rate for Payer: Aetna Commercial |
$1,351.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.41
|
| Rate for Payer: Cash Price |
$877.82
|
| Rate for Payer: Cigna Commercial |
$1,457.19
|
| Rate for Payer: First Health Commercial |
$1,667.87
|
| Rate for Payer: Humana Commercial |
$1,492.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,544.97
|
| Rate for Payer: Ohio Health Group HMO |
$1,316.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$351.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$228.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$544.25
|
| Rate for Payer: PHCS Commercial |
$1,685.42
|
| Rate for Payer: United Healthcare All Payer |
$1,544.97
|
|
|
GC 7F 078 AR1
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7F 078 AR1
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem Medicaid |
$268.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Humana KY Medicaid |
$268.24
|
| Rate for Payer: Kentucky WC Medicaid |
$270.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$273.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7F 078 IM
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem Medicaid |
$268.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Humana KY Medicaid |
$268.24
|
| Rate for Payer: Kentucky WC Medicaid |
$270.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$273.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7F 078 IM
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7FR 078 AL1
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem Medicaid |
$268.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Humana KY Medicaid |
$268.24
|
| Rate for Payer: Kentucky WC Medicaid |
$270.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$273.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7FR 078 AL1
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7FR 078 AL1 SH
|
Facility
|
OP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem Medicaid |
$268.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Humana KY Medicaid |
$268.24
|
| Rate for Payer: Kentucky WC Medicaid |
$270.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$273.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
|
GC 7FR 078 AL1 SH
|
Facility
|
IP
|
$780.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.40 |
| Max. Negotiated Rate |
$748.80 |
| Rate for Payer: Aetna Commercial |
$600.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$608.40
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$647.40
|
| Rate for Payer: First Health Commercial |
$741.00
|
| Rate for Payer: Humana Commercial |
$663.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$639.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$575.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$686.40
|
| Rate for Payer: Ohio Health Group HMO |
$585.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$241.80
|
| Rate for Payer: PHCS Commercial |
$748.80
|
| Rate for Payer: United Healthcare All Payer |
$686.40
|
|
