|
GRAFT Z RENU ANC AX1-2-32-113
|
Facility
|
OP
|
$27,886.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,625.21 |
| Max. Negotiated Rate |
$26,770.80 |
| Rate for Payer: Aetna Commercial |
$21,472.41
|
| Rate for Payer: Anthem Medicaid |
$9,590.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,751.28
|
| Rate for Payer: Cash Price |
$13,943.12
|
| Rate for Payer: Cigna Commercial |
$23,145.59
|
| Rate for Payer: First Health Commercial |
$26,491.94
|
| Rate for Payer: Humana Commercial |
$23,703.31
|
| Rate for Payer: Humana KY Medicaid |
$9,590.08
|
| Rate for Payer: Kentucky WC Medicaid |
$9,687.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,866.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,580.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,365.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,782.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,539.90
|
| Rate for Payer: Ohio Health Group HMO |
$20,914.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,577.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,625.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,644.74
|
| Rate for Payer: PHCS Commercial |
$26,770.80
|
| Rate for Payer: United Healthcare All Payer |
$24,539.90
|
|
|
GRAFT Z RENU ANC AX1-2-32-113
|
Facility
|
IP
|
$27,886.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,625.21 |
| Max. Negotiated Rate |
$26,770.80 |
| Rate for Payer: Aetna Commercial |
$21,472.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,751.28
|
| Rate for Payer: Cash Price |
$13,943.12
|
| Rate for Payer: Cigna Commercial |
$23,145.59
|
| Rate for Payer: First Health Commercial |
$26,491.94
|
| Rate for Payer: Humana Commercial |
$23,703.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,866.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,580.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,365.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,539.90
|
| Rate for Payer: Ohio Health Group HMO |
$20,914.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,577.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,625.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,644.74
|
| Rate for Payer: PHCS Commercial |
$26,770.80
|
| Rate for Payer: United Healthcare All Payer |
$24,539.90
|
|
|
GRAFT Z RENU ANC AX1-2-36-127
|
Facility
|
OP
|
$27,886.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,625.21 |
| Max. Negotiated Rate |
$26,770.80 |
| Rate for Payer: Aetna Commercial |
$21,472.41
|
| Rate for Payer: Anthem Medicaid |
$9,590.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,751.28
|
| Rate for Payer: Cash Price |
$13,943.12
|
| Rate for Payer: Cigna Commercial |
$23,145.59
|
| Rate for Payer: First Health Commercial |
$26,491.94
|
| Rate for Payer: Humana Commercial |
$23,703.31
|
| Rate for Payer: Humana KY Medicaid |
$9,590.08
|
| Rate for Payer: Kentucky WC Medicaid |
$9,687.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,866.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,580.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,365.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,782.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,539.90
|
| Rate for Payer: Ohio Health Group HMO |
$20,914.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,577.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,625.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,644.74
|
| Rate for Payer: PHCS Commercial |
$26,770.80
|
| Rate for Payer: United Healthcare All Payer |
$24,539.90
|
|
|
GRAFT Z RENU ANC AX1-2-36-127
|
Facility
|
IP
|
$27,886.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,625.21 |
| Max. Negotiated Rate |
$26,770.80 |
| Rate for Payer: Aetna Commercial |
$21,472.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21,751.28
|
| Rate for Payer: Cash Price |
$13,943.12
|
| Rate for Payer: Cigna Commercial |
$23,145.59
|
| Rate for Payer: First Health Commercial |
$26,491.94
|
| Rate for Payer: Humana Commercial |
$23,703.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,866.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20,580.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,365.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$24,539.90
|
| Rate for Payer: Ohio Health Group HMO |
$20,914.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,577.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,625.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,644.74
|
| Rate for Payer: PHCS Commercial |
$26,770.80
|
| Rate for Payer: United Healthcare All Payer |
$24,539.90
|
|
|
GRAM STAIN / BV SCORE
|
Facility
|
OP
|
$57.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem Medicaid |
$4.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Humana KY Medicaid |
$4.27
|
| Rate for Payer: Humana Medicare Advantage |
$4.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.67
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
GRAM STAIN / BV SCORE
|
Professional
|
Both
|
$57.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$57.00 |
| Rate for Payer: Aetna Commercial |
$5.49
|
| Rate for Payer: Buckeye Medicare Advantage |
$57.00
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$6.12
|
| Rate for Payer: Healthspan PPO |
$4.47
|
| Rate for Payer: Multiplan PHCS |
$34.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$39.90
|
| Rate for Payer: UHCCP Medicaid |
$19.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2.56
|
|
|
GRAM STAIN / BV SCORE
|
Facility
|
IP
|
$57.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$7.41 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$43.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.77
|
| Rate for Payer: Cash Price |
$28.50
|
| Rate for Payer: Cigna Commercial |
$47.31
|
| Rate for Payer: First Health Commercial |
$54.15
|
| Rate for Payer: Humana Commercial |
$48.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$46.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$17.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$50.16
|
| Rate for Payer: Ohio Health Group HMO |
$42.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.67
|
| Rate for Payer: PHCS Commercial |
$54.72
|
| Rate for Payer: United Healthcare All Payer |
$50.16
|
|
|
GRAND SLAM PTCA GW 300CM .014
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
GRAND SLAM PTCA GW 300CM .014
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem Medicaid |
$395.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Humana KY Medicaid |
$395.83
|
| Rate for Payer: Kentucky WC Medicaid |
$399.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
GRANISETRON 0.1mg (1mg SDV)
|
Facility
|
OP
|
$54.50
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
25004376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.08 |
| Max. Negotiated Rate |
$52.32 |
| Rate for Payer: Anthem Medicaid |
$18.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.51
|
| Rate for Payer: Cash Price |
$27.25
|
| Rate for Payer: Cigna Commercial |
$45.24
|
| Rate for Payer: First Health Commercial |
$51.78
|
| Rate for Payer: Humana Commercial |
$46.32
|
| Rate for Payer: Humana KY Medicaid |
$18.74
|
| Rate for Payer: Kentucky WC Medicaid |
$18.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$19.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.96
|
| Rate for Payer: Ohio Health Group HMO |
$40.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.90
|
| Rate for Payer: PHCS Commercial |
$52.32
|
| Rate for Payer: United Healthcare All Payer |
$47.96
|
| Rate for Payer: Aetna Commercial |
$41.96
|
|
|
GRANISETRON 0.1mg (1mg SDV)
|
Facility
|
IP
|
$54.50
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
25004376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.08 |
| Max. Negotiated Rate |
$52.32 |
| Rate for Payer: Aetna Commercial |
$41.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.51
|
| Rate for Payer: Cash Price |
$27.25
|
| Rate for Payer: Cigna Commercial |
$45.24
|
| Rate for Payer: First Health Commercial |
$51.78
|
| Rate for Payer: Humana Commercial |
$46.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$44.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$40.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$47.96
|
| Rate for Payer: Ohio Health Group HMO |
$40.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.90
|
| Rate for Payer: PHCS Commercial |
$52.32
|
| Rate for Payer: United Healthcare All Payer |
$47.96
|
|
|
GRANIX EAMCG(300MCG/0.5ML SYR)
|
Facility
|
IP
|
$1,361.74
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
25002058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$177.03 |
| Max. Negotiated Rate |
$1,307.27 |
| Rate for Payer: Aetna Commercial |
$1,048.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,062.16
|
| Rate for Payer: Cash Price |
$680.87
|
| Rate for Payer: Cigna Commercial |
$1,130.24
|
| Rate for Payer: First Health Commercial |
$1,293.65
|
| Rate for Payer: Humana Commercial |
$1,157.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,116.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,004.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$408.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,198.33
|
| Rate for Payer: Ohio Health Group HMO |
$1,021.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$272.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$177.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$422.14
|
| Rate for Payer: PHCS Commercial |
$1,307.27
|
| Rate for Payer: United Healthcare All Payer |
$1,198.33
|
|
|
GRANIX EAMCG(300MCG/0.5ML SYR)
|
Facility
|
OP
|
$1,361.74
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
25002058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1,307.27 |
| Rate for Payer: Aetna Commercial |
$1,048.54
|
| Rate for Payer: Anthem Medicaid |
$468.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,062.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$680.87
|
| Rate for Payer: Cash Price |
$680.87
|
| Rate for Payer: Cigna Commercial |
$1,130.24
|
| Rate for Payer: First Health Commercial |
$1,293.65
|
| Rate for Payer: Humana Commercial |
$1,157.48
|
| Rate for Payer: Humana KY Medicaid |
$468.30
|
| Rate for Payer: Humana Medicare Advantage |
$0.44
|
| Rate for Payer: Kentucky WC Medicaid |
$473.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,116.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,004.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$477.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,198.33
|
| Rate for Payer: Ohio Health Group HMO |
$1,021.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$272.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$177.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$422.14
|
| Rate for Payer: PHCS Commercial |
$1,307.27
|
| Rate for Payer: United Healthcare All Payer |
$1,198.33
|
|
|
GRANIX EAMCG(480MCG/0.8ML SYR)
|
Facility
|
IP
|
$2,179.40
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
25002059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$283.32 |
| Max. Negotiated Rate |
$2,092.22 |
| Rate for Payer: Aetna Commercial |
$1,678.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,699.93
|
| Rate for Payer: Cash Price |
$1,089.70
|
| Rate for Payer: Cigna Commercial |
$1,808.90
|
| Rate for Payer: First Health Commercial |
$2,070.43
|
| Rate for Payer: Humana Commercial |
$1,852.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,787.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$653.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,917.87
|
| Rate for Payer: Ohio Health Group HMO |
$1,634.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$283.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$675.61
|
| Rate for Payer: PHCS Commercial |
$2,092.22
|
| Rate for Payer: United Healthcare All Payer |
$1,917.87
|
|
|
GRANIX EAMCG(480MCG/0.8ML SYR)
|
Facility
|
OP
|
$2,179.40
|
|
|
Service Code
|
HCPCS J1442
|
| Hospital Charge Code |
25002059
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2,092.22 |
| Rate for Payer: Aetna Commercial |
$1,678.14
|
| Rate for Payer: Anthem Medicaid |
$749.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$0.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,699.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$1.33
|
| Rate for Payer: Cash Price |
$1,089.70
|
| Rate for Payer: Cash Price |
$1,089.70
|
| Rate for Payer: Cigna Commercial |
$1,808.90
|
| Rate for Payer: First Health Commercial |
$2,070.43
|
| Rate for Payer: Humana Commercial |
$1,852.49
|
| Rate for Payer: Humana KY Medicaid |
$749.50
|
| Rate for Payer: Humana Medicare Advantage |
$0.99
|
| Rate for Payer: Kentucky WC Medicaid |
$757.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,787.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,608.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$764.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,917.87
|
| Rate for Payer: Ohio Health Group HMO |
$1,634.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$435.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$283.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$675.61
|
| Rate for Payer: PHCS Commercial |
$2,092.22
|
| Rate for Payer: United Healthcare All Payer |
$1,917.87
|
|
|
GREENFIELD CAVA FILTER JUGULAR
|
Facility
|
OP
|
$5,490.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$713.70 |
| Max. Negotiated Rate |
$5,270.40 |
| Rate for Payer: Aetna Commercial |
$4,227.30
|
| Rate for Payer: Anthem Medicaid |
$1,888.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,282.20
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cigna Commercial |
$4,556.70
|
| Rate for Payer: First Health Commercial |
$5,215.50
|
| Rate for Payer: Humana Commercial |
$4,666.50
|
| Rate for Payer: Humana KY Medicaid |
$1,888.01
|
| Rate for Payer: Kentucky WC Medicaid |
$1,907.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,501.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,051.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,647.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,925.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,831.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,117.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,098.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$713.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,701.90
|
| Rate for Payer: PHCS Commercial |
$5,270.40
|
| Rate for Payer: United Healthcare All Payer |
$4,831.20
|
|
|
GREENFIELD CAVA FILTER JUGULAR
|
Facility
|
IP
|
$5,490.00
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$713.70 |
| Max. Negotiated Rate |
$5,270.40 |
| Rate for Payer: Aetna Commercial |
$4,227.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,282.20
|
| Rate for Payer: Cash Price |
$2,745.00
|
| Rate for Payer: Cigna Commercial |
$4,556.70
|
| Rate for Payer: First Health Commercial |
$5,215.50
|
| Rate for Payer: Humana Commercial |
$4,666.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,501.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,051.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,647.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,831.20
|
| Rate for Payer: Ohio Health Group HMO |
$4,117.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,098.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$713.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,701.90
|
| Rate for Payer: PHCS Commercial |
$5,270.40
|
| Rate for Payer: United Healthcare All Payer |
$4,831.20
|
|
|
GREENFIELD VENA CAVA FEMORAL
|
Facility
|
OP
|
$5,528.50
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.70 |
| Max. Negotiated Rate |
$5,307.36 |
| Rate for Payer: Aetna Commercial |
$4,256.94
|
| Rate for Payer: Anthem Medicaid |
$1,901.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,312.23
|
| Rate for Payer: Cash Price |
$2,764.25
|
| Rate for Payer: Cigna Commercial |
$4,588.66
|
| Rate for Payer: First Health Commercial |
$5,252.08
|
| Rate for Payer: Humana Commercial |
$4,699.22
|
| Rate for Payer: Humana KY Medicaid |
$1,901.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,920.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,533.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,080.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,658.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,939.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,865.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,146.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,713.84
|
| Rate for Payer: PHCS Commercial |
$5,307.36
|
| Rate for Payer: United Healthcare All Payer |
$4,865.08
|
|
|
GREENFIELD VENA CAVA FEMORAL
|
Facility
|
IP
|
$5,528.50
|
|
|
Service Code
|
HCPCS C1880
|
| Hospital Charge Code |
27000050
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.70 |
| Max. Negotiated Rate |
$5,307.36 |
| Rate for Payer: Aetna Commercial |
$4,256.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,312.23
|
| Rate for Payer: Cash Price |
$2,764.25
|
| Rate for Payer: Cigna Commercial |
$4,588.66
|
| Rate for Payer: First Health Commercial |
$5,252.08
|
| Rate for Payer: Humana Commercial |
$4,699.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,533.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,080.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,658.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,865.08
|
| Rate for Payer: Ohio Health Group HMO |
$4,146.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,713.84
|
| Rate for Payer: PHCS Commercial |
$5,307.36
|
| Rate for Payer: United Healthcare All Payer |
$4,865.08
|
|
|
GRFG AUTOL FAT LIPO 25 CC/<
|
Professional
|
Both
|
$1,188.00
|
|
|
Service Code
|
HCPCS 15773
|
| Hospital Charge Code |
76102947
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$381.50 |
| Max. Negotiated Rate |
$1,188.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$406.39
|
| Rate for Payer: Anthem Medicaid |
$381.50
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,188.00
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Humana Medicaid |
$381.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$626.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$389.13
|
| Rate for Payer: Molina Healthcare Passport |
$381.50
|
| Rate for Payer: Multiplan PHCS |
$712.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$831.60
|
| Rate for Payer: UHCCP Medicaid |
$426.71
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$385.32
|
|
|
GRFG AUTOL FAT LIPO 25 CC/<
|
Facility
|
IP
|
$1,188.00
|
|
|
Service Code
|
HCPCS 15773
|
| Hospital Charge Code |
76102947
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.44 |
| Max. Negotiated Rate |
$1,140.48 |
| Rate for Payer: Aetna Commercial |
$914.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$926.64
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cigna Commercial |
$986.04
|
| Rate for Payer: First Health Commercial |
$1,128.60
|
| Rate for Payer: Humana Commercial |
$1,009.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$974.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$876.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$356.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,045.44
|
| Rate for Payer: Ohio Health Group HMO |
$891.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$237.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.28
|
| Rate for Payer: PHCS Commercial |
$1,140.48
|
| Rate for Payer: United Healthcare All Payer |
$1,045.44
|
|
|
GRFG AUTOL FAT LIPO 25 CC/<
|
Facility
|
OP
|
$1,188.00
|
|
|
Service Code
|
HCPCS 15773
|
| Hospital Charge Code |
76102947
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$154.44 |
| Max. Negotiated Rate |
$2,207.77 |
| Rate for Payer: Aetna Commercial |
$914.76
|
| Rate for Payer: Anthem Medicaid |
$408.55
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,576.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$926.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,207.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,128.92
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cash Price |
$594.00
|
| Rate for Payer: Cigna Commercial |
$986.04
|
| Rate for Payer: First Health Commercial |
$1,128.60
|
| Rate for Payer: Humana Commercial |
$1,009.80
|
| Rate for Payer: Humana KY Medicaid |
$408.55
|
| Rate for Payer: Humana Medicare Advantage |
$1,576.98
|
| Rate for Payer: Kentucky WC Medicaid |
$412.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$974.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$876.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,892.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$416.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,045.44
|
| Rate for Payer: Ohio Health Group HMO |
$891.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$237.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$154.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$368.28
|
| Rate for Payer: PHCS Commercial |
$1,140.48
|
| Rate for Payer: United Healthcare All Payer |
$1,045.44
|
|
|
GRFG AUTOL FAT LIPO 50 CC/<
|
Facility
|
IP
|
$680.00
|
|
|
Service Code
|
HCPCS 15771
|
| Hospital Charge Code |
76102620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$652.80 |
| Rate for Payer: Aetna Commercial |
$523.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$530.40
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$646.00
|
| Rate for Payer: Humana Commercial |
$578.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$204.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$598.40
|
| Rate for Payer: Ohio Health Group HMO |
$510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.80
|
| Rate for Payer: PHCS Commercial |
$652.80
|
| Rate for Payer: United Healthcare All Payer |
$598.40
|
|
|
GRFG AUTOL FAT LIPO 50 CC/<
|
Facility
|
OP
|
$680.00
|
|
|
Service Code
|
HCPCS 15771
|
| Hospital Charge Code |
76102620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$88.40 |
| Max. Negotiated Rate |
$4,343.37 |
| Rate for Payer: Aetna Commercial |
$523.60
|
| Rate for Payer: Anthem Medicaid |
$233.85
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,102.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$530.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,343.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,188.25
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cigna Commercial |
$564.40
|
| Rate for Payer: First Health Commercial |
$646.00
|
| Rate for Payer: Humana Commercial |
$578.00
|
| Rate for Payer: Humana KY Medicaid |
$233.85
|
| Rate for Payer: Humana Medicare Advantage |
$3,102.41
|
| Rate for Payer: Kentucky WC Medicaid |
$236.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$557.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$501.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$238.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$598.40
|
| Rate for Payer: Ohio Health Group HMO |
$510.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$136.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$88.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$210.80
|
| Rate for Payer: PHCS Commercial |
$652.80
|
| Rate for Payer: United Healthcare All Payer |
$598.40
|
|
|
GRFG AUTOL FAT LIPO 50 CC/<
|
Professional
|
Both
|
$680.00
|
|
|
Service Code
|
HCPCS 15771
|
| Hospital Charge Code |
761P2620
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$377.28 |
| Max. Negotiated Rate |
$680.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$382.86
|
| Rate for Payer: Anthem Medicaid |
$377.28
|
| Rate for Payer: Buckeye Medicare Advantage |
$680.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Cash Price |
$340.00
|
| Rate for Payer: Humana Medicaid |
$377.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$620.19
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.83
|
| Rate for Payer: Molina Healthcare Passport |
$377.28
|
| Rate for Payer: Multiplan PHCS |
$408.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$476.00
|
| Rate for Payer: UHCCP Medicaid |
$402.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$381.05
|
|
