|
FIBERTAK DBL LD W/ 1.3 SUT TPE
|
Facility
|
IP
|
$3,387.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,016.25 |
| Max. Negotiated Rate |
$3,252.00 |
| Rate for Payer: Aetna Commercial |
$2,608.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,642.25
|
| Rate for Payer: Cash Price |
$1,693.75
|
| Rate for Payer: Cigna Commercial |
$2,811.62
|
| Rate for Payer: First Health Commercial |
$3,218.12
|
| Rate for Payer: Humana Commercial |
$2,879.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,777.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,499.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,016.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,981.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,540.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,710.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,947.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,337.38
|
| Rate for Payer: PHCS Commercial |
$3,252.00
|
| Rate for Payer: United Healthcare All Payer |
$2,981.00
|
|
|
FIBERTAK RC SP 2.6 TIGERTAPE
|
Facility
|
IP
|
$3,850.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.19 |
| Max. Negotiated Rate |
$3,696.60 |
| Rate for Payer: Aetna Commercial |
$2,964.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,003.48
|
| Rate for Payer: Cash Price |
$1,925.31
|
| Rate for Payer: Cigna Commercial |
$3,196.01
|
| Rate for Payer: First Health Commercial |
$3,658.09
|
| Rate for Payer: Humana Commercial |
$3,273.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,841.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,388.55
|
| Rate for Payer: Ohio Health Group HMO |
$2,887.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,080.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,350.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,656.93
|
| Rate for Payer: PHCS Commercial |
$3,696.60
|
| Rate for Payer: United Healthcare All Payer |
$3,388.55
|
|
|
FIBERTAK RC SP 2.6 TIGERTAPE
|
Facility
|
OP
|
$3,850.62
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.19 |
| Max. Negotiated Rate |
$3,696.60 |
| Rate for Payer: Aetna Commercial |
$2,964.98
|
| Rate for Payer: Anthem Medicaid |
$1,324.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,003.48
|
| Rate for Payer: Cash Price |
$1,925.31
|
| Rate for Payer: Cigna Commercial |
$3,196.01
|
| Rate for Payer: First Health Commercial |
$3,658.09
|
| Rate for Payer: Humana Commercial |
$3,273.03
|
| Rate for Payer: Humana KY Medicaid |
$1,324.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,337.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,157.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,841.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,155.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,388.55
|
| Rate for Payer: Ohio Health Group HMO |
$2,887.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,080.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,350.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,656.93
|
| Rate for Payer: PHCS Commercial |
$3,696.60
|
| Rate for Payer: United Healthcare All Payer |
$3,388.55
|
|
|
FIBERTAK SPEEDBRIDGE IMPLANT
|
Facility
|
IP
|
$13,023.65
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,907.09 |
| Max. Negotiated Rate |
$12,502.70 |
| Rate for Payer: Aetna Commercial |
$10,028.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,158.45
|
| Rate for Payer: Cash Price |
$6,511.82
|
| Rate for Payer: Cigna Commercial |
$10,809.63
|
| Rate for Payer: First Health Commercial |
$12,372.47
|
| Rate for Payer: Humana Commercial |
$11,070.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,679.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,611.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,907.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,460.81
|
| Rate for Payer: Ohio Health Group HMO |
$9,767.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,418.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,330.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,986.32
|
| Rate for Payer: PHCS Commercial |
$12,502.70
|
| Rate for Payer: United Healthcare All Payer |
$11,460.81
|
|
|
FIBERTAK SPEEDBRIDGE IMPLANT
|
Facility
|
OP
|
$13,023.65
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,907.09 |
| Max. Negotiated Rate |
$12,502.70 |
| Rate for Payer: Aetna Commercial |
$10,028.21
|
| Rate for Payer: Anthem Medicaid |
$4,478.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,158.45
|
| Rate for Payer: Cash Price |
$6,511.82
|
| Rate for Payer: Cigna Commercial |
$10,809.63
|
| Rate for Payer: First Health Commercial |
$12,372.47
|
| Rate for Payer: Humana Commercial |
$11,070.10
|
| Rate for Payer: Humana KY Medicaid |
$4,478.83
|
| Rate for Payer: Kentucky WC Medicaid |
$4,524.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,679.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,611.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,907.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,568.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,460.81
|
| Rate for Payer: Ohio Health Group HMO |
$9,767.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,418.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,330.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,986.32
|
| Rate for Payer: PHCS Commercial |
$12,502.70
|
| Rate for Payer: United Healthcare All Payer |
$11,460.81
|
|
|
FIBERTK KNOTLESS TIGRTPE 2.6
|
Facility
|
OP
|
$13,711.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,113.53 |
| Max. Negotiated Rate |
$13,163.30 |
| Rate for Payer: Aetna Commercial |
$10,558.06
|
| Rate for Payer: Anthem Medicaid |
$4,715.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,695.18
|
| Rate for Payer: Cash Price |
$6,855.89
|
| Rate for Payer: Cigna Commercial |
$11,380.77
|
| Rate for Payer: First Health Commercial |
$13,026.18
|
| Rate for Payer: Humana Commercial |
$11,655.00
|
| Rate for Payer: Humana KY Medicaid |
$4,715.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,763.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,243.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,119.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,113.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,810.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,066.36
|
| Rate for Payer: Ohio Health Group HMO |
$10,283.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,969.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,929.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,461.12
|
| Rate for Payer: PHCS Commercial |
$13,163.30
|
| Rate for Payer: United Healthcare All Payer |
$12,066.36
|
|
|
FIBERTK KNOTLESS TIGRTPE 2.6
|
Facility
|
IP
|
$13,711.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,113.53 |
| Max. Negotiated Rate |
$13,163.30 |
| Rate for Payer: Aetna Commercial |
$10,558.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,695.18
|
| Rate for Payer: Cash Price |
$6,855.89
|
| Rate for Payer: Cigna Commercial |
$11,380.77
|
| Rate for Payer: First Health Commercial |
$13,026.18
|
| Rate for Payer: Humana Commercial |
$11,655.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,243.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,119.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,113.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,066.36
|
| Rate for Payer: Ohio Health Group HMO |
$10,283.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,969.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,929.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,461.12
|
| Rate for Payer: PHCS Commercial |
$13,163.30
|
| Rate for Payer: United Healthcare All Payer |
$12,066.36
|
|
|
FIBRINOGEN
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
HCPCS 85384
|
| Hospital Charge Code |
30000604
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.72 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Aetna Commercial |
$93.17
|
| Rate for Payer: Anthem Medicaid |
$9.72
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.72
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Humana KY Medicaid |
$9.72
|
| Rate for Payer: Humana Medicare Advantage |
$9.72
|
| Rate for Payer: Kentucky WC Medicaid |
$9.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.49
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
|
|
FIBRINOGEN
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
HCPCS 85384
|
| Hospital Charge Code |
30000604
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$36.30 |
| Max. Negotiated Rate |
$116.16 |
| Rate for Payer: Aetna Commercial |
$93.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.16
|
| Rate for Payer: Cash Price |
$60.50
|
| Rate for Payer: Cigna Commercial |
$100.43
|
| Rate for Payer: First Health Commercial |
$114.95
|
| Rate for Payer: Humana Commercial |
$102.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$99.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$89.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$106.48
|
| Rate for Payer: Ohio Health Group HMO |
$90.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$105.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.49
|
| Rate for Payer: PHCS Commercial |
$116.16
|
| Rate for Payer: United Healthcare All Payer |
$106.48
|
|
|
FIELDER FC PTCA GW 180CM
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
FIELDER FC PTCA GW 180CM
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
FIELDER FC PTCA GW 300CM
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
FIELDER FC PTCA GW 300CM
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
FIELDER PTCA GW 180CM
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
FIELDER PTCA GW 180CM
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
FIELDER XT PTCA GW 190CM
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem Medicaid |
$603.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Humana KY Medicaid |
$603.89
|
| Rate for Payer: Kentucky WC Medicaid |
$610.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
FIELDER XT PTCA GW 190CM
|
Facility
|
IP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
FIELDER XT PTCA GW 300CM
|
Facility
|
IP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
FIELDER XT PTCA GW 300CM
|
Facility
|
OP
|
$1,756.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$526.80 |
| Max. Negotiated Rate |
$1,685.76 |
| Rate for Payer: Aetna Commercial |
$1,352.12
|
| Rate for Payer: Anthem Medicaid |
$603.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,369.68
|
| Rate for Payer: Cash Price |
$878.00
|
| Rate for Payer: Cigna Commercial |
$1,457.48
|
| Rate for Payer: First Health Commercial |
$1,668.20
|
| Rate for Payer: Humana Commercial |
$1,492.60
|
| Rate for Payer: Humana KY Medicaid |
$603.89
|
| Rate for Payer: Kentucky WC Medicaid |
$610.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,439.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,295.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$526.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$616.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,545.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,317.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,404.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,527.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,211.64
|
| Rate for Payer: PHCS Commercial |
$1,685.76
|
| Rate for Payer: United Healthcare All Payer |
$1,545.28
|
|
|
FIELD HOSPITAL ROOM RATE
|
Facility
|
IP
|
$500.00
|
|
| Hospital Charge Code |
11000014
|
|
Hospital Revenue Code
|
150
|
| Min. Negotiated Rate |
$150.00 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$385.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$390.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$415.00
|
| Rate for Payer: First Health Commercial |
$475.00
|
| Rate for Payer: Humana Commercial |
$425.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$410.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$369.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$150.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$440.00
|
| Rate for Payer: Ohio Health Group HMO |
$375.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$435.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$345.00
|
| Rate for Payer: PHCS Commercial |
$480.00
|
| Rate for Payer: United Healthcare All Payer |
$440.00
|
|
|
FILARIA BLOOD
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
HCPCS 87207
|
| Hospital Charge Code |
30001331
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Aetna Commercial |
$73.92
|
| Rate for Payer: Anthem Medicaid |
$5.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.09
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.99
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$79.68
|
| Rate for Payer: First Health Commercial |
$91.20
|
| Rate for Payer: Humana Commercial |
$81.60
|
| Rate for Payer: Humana KY Medicaid |
$5.99
|
| Rate for Payer: Humana Medicare Advantage |
$5.99
|
| Rate for Payer: Kentucky WC Medicaid |
$6.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.48
|
| Rate for Payer: Ohio Health Group HMO |
$72.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.24
|
| Rate for Payer: PHCS Commercial |
$92.16
|
| Rate for Payer: United Healthcare All Payer |
$84.48
|
|
|
FILARIA BLOOD
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
HCPCS 87207
|
| Hospital Charge Code |
30001331
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$92.16 |
| Rate for Payer: Aetna Commercial |
$73.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$77.09
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna Commercial |
$79.68
|
| Rate for Payer: First Health Commercial |
$91.20
|
| Rate for Payer: Humana Commercial |
$81.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$84.48
|
| Rate for Payer: Ohio Health Group HMO |
$72.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66.24
|
| Rate for Payer: PHCS Commercial |
$92.16
|
| Rate for Payer: United Healthcare All Payer |
$84.48
|
|
|
FILLETED FINGER/TOE FLAP
|
Professional
|
Both
|
$875.00
|
|
|
Service Code
|
HCPCS 14350
|
| Hospital Charge Code |
76102680
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$306.25 |
| Max. Negotiated Rate |
$1,090.93 |
| Rate for Payer: Aetna Commercial |
$1,090.93
|
| Rate for Payer: Ambetter Exchange |
$628.80
|
| Rate for Payer: Anthem Medicaid |
$453.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$628.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$628.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$754.56
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Cigna Commercial |
$1,043.02
|
| Rate for Payer: Healthspan PPO |
$872.29
|
| Rate for Payer: Humana Medicaid |
$453.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$898.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$628.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$628.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$462.96
|
| Rate for Payer: Molina Healthcare Passport |
$453.88
|
| Rate for Payer: Multiplan PHCS |
$525.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$817.44
|
| Rate for Payer: UHCCP Medicaid |
$306.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$458.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$628.80
|
|
|
FILL POLYMER KIT SEAL TV-CS14-
|
Facility
|
OP
|
$5,746.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,723.88 |
| Max. Negotiated Rate |
$5,516.40 |
| Rate for Payer: Aetna Commercial |
$4,424.61
|
| Rate for Payer: Anthem Medicaid |
$1,976.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,482.07
|
| Rate for Payer: Cash Price |
$2,873.12
|
| Rate for Payer: Cigna Commercial |
$4,769.39
|
| Rate for Payer: First Health Commercial |
$5,458.94
|
| Rate for Payer: Humana Commercial |
$4,884.31
|
| Rate for Payer: Humana KY Medicaid |
$1,976.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,996.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,711.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,240.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,723.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,015.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,056.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,309.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,597.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,999.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.91
|
| Rate for Payer: PHCS Commercial |
$5,516.40
|
| Rate for Payer: United Healthcare All Payer |
$5,056.70
|
|
|
FILL POLYMER KIT SEAL TV-CS14-
|
Facility
|
IP
|
$5,746.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,723.88 |
| Max. Negotiated Rate |
$5,516.40 |
| Rate for Payer: Aetna Commercial |
$4,424.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,482.07
|
| Rate for Payer: Cash Price |
$2,873.12
|
| Rate for Payer: Cigna Commercial |
$4,769.39
|
| Rate for Payer: First Health Commercial |
$5,458.94
|
| Rate for Payer: Humana Commercial |
$4,884.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,711.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,240.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,723.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,056.70
|
| Rate for Payer: Ohio Health Group HMO |
$4,309.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,597.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,999.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.91
|
| Rate for Payer: PHCS Commercial |
$5,516.40
|
| Rate for Payer: United Healthcare All Payer |
$5,056.70
|
|
