|
GONIOTOMY
|
Facility
|
OP
|
$4,922.33
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,515.95 |
| Max. Negotiated Rate |
$4,922.33 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,515.95
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,922.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,746.53
|
| Rate for Payer: Humana Medicare Advantage |
$3,515.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,219.14
|
|
|
GONORRHEA AMPLIF DNA PROBE
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
30001384
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$19.37 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$119.65
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Humana KY Medicaid |
$35.09
|
| Rate for Payer: Humana Medicare Advantage |
$35.09
|
| Rate for Payer: Kentucky WC Medicaid |
$35.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.19
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
GONORRHEA AMPLIF DNA PROBE
|
Professional
|
Both
|
$149.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
30001384
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$149.00 |
| Rate for Payer: Aetna Commercial |
$45.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$149.00
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$30.93
|
| Rate for Payer: Healthspan PPO |
$65.00
|
| Rate for Payer: Multiplan PHCS |
$89.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$104.30
|
| Rate for Payer: UHCCP Medicaid |
$52.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.05
|
|
|
GONORRHEA AMPLIF DNA PROBE
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
30001384
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$19.37 |
| Max. Negotiated Rate |
$143.04 |
| Rate for Payer: Aetna Commercial |
$114.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$119.65
|
| Rate for Payer: Cash Price |
$74.50
|
| Rate for Payer: Cigna Commercial |
$123.67
|
| Rate for Payer: First Health Commercial |
$141.55
|
| Rate for Payer: Humana Commercial |
$126.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$122.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$131.12
|
| Rate for Payer: Ohio Health Group HMO |
$111.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.19
|
| Rate for Payer: PHCS Commercial |
$143.04
|
| Rate for Payer: United Healthcare All Payer |
$131.12
|
|
|
GOOS FEATHERS IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000700
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
GOOS FEATHERS IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000700
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
GPS III DBLE KIT W/30ML ACDA
|
Facility
|
OP
|
$9,516.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.08 |
| Max. Negotiated Rate |
$9,135.36 |
| Rate for Payer: Aetna Commercial |
$7,327.32
|
| Rate for Payer: Anthem Medicaid |
$3,272.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,422.48
|
| Rate for Payer: Cash Price |
$4,758.00
|
| Rate for Payer: Cigna Commercial |
$7,898.28
|
| Rate for Payer: First Health Commercial |
$9,040.20
|
| Rate for Payer: Humana Commercial |
$8,088.60
|
| Rate for Payer: Humana KY Medicaid |
$3,272.55
|
| Rate for Payer: Kentucky WC Medicaid |
$3,305.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,803.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,022.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,854.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,338.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,374.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,137.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,903.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,949.96
|
| Rate for Payer: PHCS Commercial |
$9,135.36
|
| Rate for Payer: United Healthcare All Payer |
$8,374.08
|
|
|
GPS III DBLE KIT W/30ML ACDA
|
Facility
|
IP
|
$9,516.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,237.08 |
| Max. Negotiated Rate |
$9,135.36 |
| Rate for Payer: Aetna Commercial |
$7,327.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,422.48
|
| Rate for Payer: Cash Price |
$4,758.00
|
| Rate for Payer: Cigna Commercial |
$7,898.28
|
| Rate for Payer: First Health Commercial |
$9,040.20
|
| Rate for Payer: Humana Commercial |
$8,088.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,803.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,022.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,854.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,374.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,137.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,903.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,237.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,949.96
|
| Rate for Payer: PHCS Commercial |
$9,135.36
|
| Rate for Payer: United Healthcare All Payer |
$8,374.08
|
|
|
GPS III MINI KIT W/30ML ACDA
|
Facility
|
IP
|
$5,084.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$660.92 |
| Max. Negotiated Rate |
$4,880.64 |
| Rate for Payer: Aetna Commercial |
$3,914.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,965.52
|
| Rate for Payer: Cash Price |
$2,542.00
|
| Rate for Payer: Cigna Commercial |
$4,219.72
|
| Rate for Payer: First Health Commercial |
$4,829.80
|
| Rate for Payer: Humana Commercial |
$4,321.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,168.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,751.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,525.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,473.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,813.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,016.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$660.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,576.04
|
| Rate for Payer: PHCS Commercial |
$4,880.64
|
| Rate for Payer: United Healthcare All Payer |
$4,473.92
|
|
|
GPS III MINI KIT W/30ML ACDA
|
Facility
|
OP
|
$5,084.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$660.92 |
| Max. Negotiated Rate |
$4,880.64 |
| Rate for Payer: Aetna Commercial |
$3,914.68
|
| Rate for Payer: Anthem Medicaid |
$1,748.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,965.52
|
| Rate for Payer: Cash Price |
$2,542.00
|
| Rate for Payer: Cigna Commercial |
$4,219.72
|
| Rate for Payer: First Health Commercial |
$4,829.80
|
| Rate for Payer: Humana Commercial |
$4,321.40
|
| Rate for Payer: Humana KY Medicaid |
$1,748.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,766.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,168.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,751.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,525.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,783.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,473.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,813.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,016.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$660.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,576.04
|
| Rate for Payer: PHCS Commercial |
$4,880.64
|
| Rate for Payer: United Healthcare All Payer |
$4,473.92
|
|
|
GPS III SINGLE KIT W/30ML ACDA
|
Facility
|
IP
|
$5,084.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$660.92 |
| Max. Negotiated Rate |
$4,880.64 |
| Rate for Payer: Aetna Commercial |
$3,914.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,965.52
|
| Rate for Payer: Cash Price |
$2,542.00
|
| Rate for Payer: Cigna Commercial |
$4,219.72
|
| Rate for Payer: First Health Commercial |
$4,829.80
|
| Rate for Payer: Humana Commercial |
$4,321.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,168.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,751.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,525.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,473.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,813.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,016.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$660.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,576.04
|
| Rate for Payer: PHCS Commercial |
$4,880.64
|
| Rate for Payer: United Healthcare All Payer |
$4,473.92
|
|
|
GPS III SINGLE KIT W/30ML ACDA
|
Facility
|
OP
|
$5,084.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$660.92 |
| Max. Negotiated Rate |
$4,880.64 |
| Rate for Payer: Aetna Commercial |
$3,914.68
|
| Rate for Payer: Anthem Medicaid |
$1,748.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,965.52
|
| Rate for Payer: Cash Price |
$2,542.00
|
| Rate for Payer: Cigna Commercial |
$4,219.72
|
| Rate for Payer: First Health Commercial |
$4,829.80
|
| Rate for Payer: Humana Commercial |
$4,321.40
|
| Rate for Payer: Humana KY Medicaid |
$1,748.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,766.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,168.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,751.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,525.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,783.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,473.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,813.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,016.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$660.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,576.04
|
| Rate for Payer: PHCS Commercial |
$4,880.64
|
| Rate for Payer: United Healthcare All Payer |
$4,473.92
|
|
|
GPSIII SPARE BUCKT KIT 60ML GR
|
Facility
|
IP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
GPSIII SPARE BUCKT KIT 60ML GR
|
Facility
|
OP
|
$1,882.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$244.66 |
| Max. Negotiated Rate |
$1,806.72 |
| Rate for Payer: Aetna Commercial |
$1,449.14
|
| Rate for Payer: Anthem Medicaid |
$647.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,467.96
|
| Rate for Payer: Cash Price |
$941.00
|
| Rate for Payer: Cigna Commercial |
$1,562.06
|
| Rate for Payer: First Health Commercial |
$1,787.90
|
| Rate for Payer: Humana Commercial |
$1,599.70
|
| Rate for Payer: Humana KY Medicaid |
$647.22
|
| Rate for Payer: Kentucky WC Medicaid |
$653.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,388.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.42
|
| Rate for Payer: PHCS Commercial |
$1,806.72
|
| Rate for Payer: United Healthcare All Payer |
$1,656.16
|
|
|
GRACILIS
|
Facility
|
OP
|
$7,271.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$945.26 |
| Max. Negotiated Rate |
$6,980.40 |
| Rate for Payer: Aetna Commercial |
$5,598.86
|
| Rate for Payer: Anthem Medicaid |
$2,500.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,671.58
|
| Rate for Payer: Cash Price |
$3,635.62
|
| Rate for Payer: Cigna Commercial |
$6,035.14
|
| Rate for Payer: First Health Commercial |
$6,907.69
|
| Rate for Payer: Humana Commercial |
$6,180.56
|
| Rate for Payer: Humana KY Medicaid |
$2,500.58
|
| Rate for Payer: Kentucky WC Medicaid |
$2,526.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,962.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,366.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,181.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,550.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,398.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,453.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$945.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,254.09
|
| Rate for Payer: PHCS Commercial |
$6,980.40
|
| Rate for Payer: United Healthcare All Payer |
$6,398.70
|
|
|
GRACILIS
|
Facility
|
IP
|
$7,271.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$945.26 |
| Max. Negotiated Rate |
$6,980.40 |
| Rate for Payer: Aetna Commercial |
$5,598.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,671.58
|
| Rate for Payer: Cash Price |
$3,635.62
|
| Rate for Payer: Cigna Commercial |
$6,035.14
|
| Rate for Payer: First Health Commercial |
$6,907.69
|
| Rate for Payer: Humana Commercial |
$6,180.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,962.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,366.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,181.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,398.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,453.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,454.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$945.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,254.09
|
| Rate for Payer: PHCS Commercial |
$6,980.40
|
| Rate for Payer: United Healthcare All Payer |
$6,398.70
|
|
|
GRAFIX PL 2CM X 3CM
|
Facility
|
OP
|
$6,614.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$859.85 |
| Max. Negotiated Rate |
$6,349.68 |
| Rate for Payer: Aetna Commercial |
$5,092.97
|
| Rate for Payer: Anthem Medicaid |
$2,274.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,159.12
|
| Rate for Payer: Cash Price |
$3,307.12
|
| Rate for Payer: Cigna Commercial |
$5,489.83
|
| Rate for Payer: First Health Commercial |
$6,283.54
|
| Rate for Payer: Humana Commercial |
$5,622.11
|
| Rate for Payer: Humana KY Medicaid |
$2,274.64
|
| Rate for Payer: Kentucky WC Medicaid |
$2,297.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,423.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,881.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,984.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,320.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,820.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,960.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,322.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,050.42
|
| Rate for Payer: PHCS Commercial |
$6,349.68
|
| Rate for Payer: United Healthcare All Payer |
$5,820.54
|
|
|
GRAFIX PL 2CM X 3CM
|
Facility
|
IP
|
$6,614.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$859.85 |
| Max. Negotiated Rate |
$6,349.68 |
| Rate for Payer: Aetna Commercial |
$5,092.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,159.12
|
| Rate for Payer: Cash Price |
$3,307.12
|
| Rate for Payer: Cigna Commercial |
$5,489.83
|
| Rate for Payer: First Health Commercial |
$6,283.54
|
| Rate for Payer: Humana Commercial |
$5,622.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,423.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,881.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,984.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,820.54
|
| Rate for Payer: Ohio Health Group HMO |
$4,960.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,322.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,050.42
|
| Rate for Payer: PHCS Commercial |
$6,349.68
|
| Rate for Payer: United Healthcare All Payer |
$5,820.54
|
|
|
GRAFT 4-7MM*40CM TAPER TS
|
Facility
|
IP
|
$3,838.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.94 |
| Max. Negotiated Rate |
$3,684.48 |
| Rate for Payer: Aetna Commercial |
$2,955.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.64
|
| Rate for Payer: Cash Price |
$1,919.00
|
| Rate for Payer: Cigna Commercial |
$3,185.54
|
| Rate for Payer: First Health Commercial |
$3,646.10
|
| Rate for Payer: Humana Commercial |
$3,262.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,147.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$498.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.78
|
| Rate for Payer: PHCS Commercial |
$3,684.48
|
| Rate for Payer: United Healthcare All Payer |
$3,377.44
|
|
|
GRAFT 4-7MM*40CM TAPER TS
|
Facility
|
OP
|
$3,838.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$498.94 |
| Max. Negotiated Rate |
$3,684.48 |
| Rate for Payer: Aetna Commercial |
$2,955.26
|
| Rate for Payer: Anthem Medicaid |
$1,319.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.64
|
| Rate for Payer: Cash Price |
$1,919.00
|
| Rate for Payer: Cigna Commercial |
$3,185.54
|
| Rate for Payer: First Health Commercial |
$3,646.10
|
| Rate for Payer: Humana Commercial |
$3,262.30
|
| Rate for Payer: Humana KY Medicaid |
$1,319.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,333.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,147.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,346.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$498.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.78
|
| Rate for Payer: PHCS Commercial |
$3,684.48
|
| Rate for Payer: United Healthcare All Payer |
$3,377.44
|
|
|
GRAFT 4-7MM*45CM TAPER
|
Facility
|
IP
|
$7,910.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,028.30 |
| Max. Negotiated Rate |
$7,593.60 |
| Rate for Payer: Aetna Commercial |
$6,090.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,169.80
|
| Rate for Payer: Cash Price |
$3,955.00
|
| Rate for Payer: Cigna Commercial |
$6,565.30
|
| Rate for Payer: First Health Commercial |
$7,514.50
|
| Rate for Payer: Humana Commercial |
$6,723.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,486.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,837.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,373.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,960.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,932.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,582.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,028.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,452.10
|
| Rate for Payer: PHCS Commercial |
$7,593.60
|
| Rate for Payer: United Healthcare All Payer |
$6,960.80
|
|
|
GRAFT 4-7MM*45CM TAPER
|
Facility
|
OP
|
$7,910.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,028.30 |
| Max. Negotiated Rate |
$7,593.60 |
| Rate for Payer: Aetna Commercial |
$6,090.70
|
| Rate for Payer: Anthem Medicaid |
$2,720.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,169.80
|
| Rate for Payer: Cash Price |
$3,955.00
|
| Rate for Payer: Cigna Commercial |
$6,565.30
|
| Rate for Payer: First Health Commercial |
$7,514.50
|
| Rate for Payer: Humana Commercial |
$6,723.50
|
| Rate for Payer: Humana KY Medicaid |
$2,720.25
|
| Rate for Payer: Kentucky WC Medicaid |
$2,747.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,486.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,837.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,373.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,774.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,960.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,932.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,582.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,028.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,452.10
|
| Rate for Payer: PHCS Commercial |
$7,593.60
|
| Rate for Payer: United Healthcare All Payer |
$6,960.80
|
|
|
GRAFT 4-7MM*45CM TAPER TS
|
Facility
|
IP
|
$4,580.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.40 |
| Max. Negotiated Rate |
$4,396.80 |
| Rate for Payer: Aetna Commercial |
$3,526.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,572.40
|
| Rate for Payer: Cash Price |
$2,290.00
|
| Rate for Payer: Cigna Commercial |
$3,801.40
|
| Rate for Payer: First Health Commercial |
$4,351.00
|
| Rate for Payer: Humana Commercial |
$3,893.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,755.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,380.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,374.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,030.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$916.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$595.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,419.80
|
| Rate for Payer: PHCS Commercial |
$4,396.80
|
| Rate for Payer: United Healthcare All Payer |
$4,030.40
|
|
|
GRAFT 4-7MM*45CM TAPER TS
|
Facility
|
OP
|
$4,580.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$595.40 |
| Max. Negotiated Rate |
$4,396.80 |
| Rate for Payer: Aetna Commercial |
$3,526.60
|
| Rate for Payer: Anthem Medicaid |
$1,575.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,572.40
|
| Rate for Payer: Cash Price |
$2,290.00
|
| Rate for Payer: Cigna Commercial |
$3,801.40
|
| Rate for Payer: First Health Commercial |
$4,351.00
|
| Rate for Payer: Humana Commercial |
$3,893.00
|
| Rate for Payer: Humana KY Medicaid |
$1,575.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,591.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,755.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,380.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,374.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,606.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,030.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$916.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$595.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,419.80
|
| Rate for Payer: PHCS Commercial |
$4,396.80
|
| Rate for Payer: United Healthcare All Payer |
$4,030.40
|
|
|
GRAFT 6MM*50CM STRAIGHT
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
