|
GOLDWIRE 300CM
|
Facility
|
OP
|
$1,949.80
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$584.94 |
| Max. Negotiated Rate |
$1,871.81 |
| Rate for Payer: Aetna Commercial |
$1,501.35
|
| Rate for Payer: Anthem Medicaid |
$670.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,520.84
|
| Rate for Payer: Cash Price |
$974.90
|
| Rate for Payer: Cigna Commercial |
$1,618.33
|
| Rate for Payer: First Health Commercial |
$1,852.31
|
| Rate for Payer: Humana Commercial |
$1,657.33
|
| Rate for Payer: Humana KY Medicaid |
$670.54
|
| Rate for Payer: Kentucky WC Medicaid |
$677.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,598.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,438.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$683.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,715.82
|
| Rate for Payer: Ohio Health Group HMO |
$1,462.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,559.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,696.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,345.36
|
| Rate for Payer: PHCS Commercial |
$1,871.81
|
| Rate for Payer: United Healthcare All Payer |
$1,715.82
|
|
|
GOLF EVALUATION
|
Facility
|
OP
|
$116.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
42000036
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem Medicaid |
$39.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Humana KY Medicaid |
$39.89
|
| Rate for Payer: Kentucky WC Medicaid |
$40.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
GOLF EVALUATION
|
Facility
|
IP
|
$116.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
42000036
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$34.80 |
| Max. Negotiated Rate |
$111.36 |
| Rate for Payer: Aetna Commercial |
$89.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.48
|
| Rate for Payer: Cash Price |
$58.00
|
| Rate for Payer: Cigna Commercial |
$96.28
|
| Rate for Payer: First Health Commercial |
$110.20
|
| Rate for Payer: Humana Commercial |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.08
|
| Rate for Payer: Ohio Health Group HMO |
$87.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$92.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.04
|
| Rate for Payer: PHCS Commercial |
$111.36
|
| Rate for Payer: United Healthcare All Payer |
$102.08
|
|
|
GOLYTELY SOLUTION (TF) 4000ML
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
25000736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
GOLYTELY SOLUTION (TF) 4000ML
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
25000736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.91
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
GONIOTOMY
|
Facility
|
OP
|
$5,203.86
|
|
|
Service Code
|
CPT 65820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,717.04 |
| Max. Negotiated Rate |
$5,203.86 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,717.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5,203.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5,018.00
|
| Rate for Payer: Humana Medicare Advantage |
$3,717.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,460.45
|
|
|
GONORRHEA AMPLIF DNA PROBE
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
30001384
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$35.09 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna Commercial |
$121.66
|
| Rate for Payer: Anthem Medicaid |
$35.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$35.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$126.87
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$49.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$35.09
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$131.14
|
| Rate for Payer: First Health Commercial |
$150.10
|
| Rate for Payer: Humana Commercial |
$134.30
|
| 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 |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.04
|
| Rate for Payer: Ohio Health Group HMO |
$118.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.02
|
| Rate for Payer: PHCS Commercial |
$151.68
|
| Rate for Payer: United Healthcare All Payer |
$139.04
|
|
|
GONORRHEA AMPLIF DNA PROBE
|
Professional
|
Both
|
$158.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
30001384
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.05 |
| Max. Negotiated Rate |
$94.80 |
| Rate for Payer: Aetna Commercial |
$45.85
|
| Rate for Payer: Ambetter Exchange |
$35.09
|
| Rate for Payer: Buckeye Individual/Medicaid |
$35.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$35.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$42.11
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$30.93
|
| Rate for Payer: Healthspan PPO |
$65.00
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$35.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.09
|
| Rate for Payer: Multiplan PHCS |
$94.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$45.62
|
| Rate for Payer: UHCCP Medicaid |
$55.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$21.05
|
| Rate for Payer: Wellcare Medicare Advantage |
$35.09
|
|
|
GONORRHEA AMPLIF DNA PROBE
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
HCPCS 87591
|
| Hospital Charge Code |
30001384
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$47.40 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna Commercial |
$121.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$126.87
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$131.14
|
| Rate for Payer: First Health Commercial |
$150.10
|
| Rate for Payer: Humana Commercial |
$134.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.04
|
| Rate for Payer: Ohio Health Group HMO |
$118.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.02
|
| Rate for Payer: PHCS Commercial |
$151.68
|
| Rate for Payer: United Healthcare All Payer |
$139.04
|
|
|
GOOS FEATHERS IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000700
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
GOOS FEATHERS IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000700
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
GPS III DBLE KIT W/30ML ACDA
|
Facility
|
OP
|
$9,716.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,914.80 |
| Max. Negotiated Rate |
$9,327.36 |
| Rate for Payer: Aetna Commercial |
$7,481.32
|
| Rate for Payer: Anthem Medicaid |
$3,341.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,578.48
|
| Rate for Payer: Cash Price |
$4,858.00
|
| Rate for Payer: Cigna Commercial |
$8,064.28
|
| Rate for Payer: First Health Commercial |
$9,230.20
|
| Rate for Payer: Humana Commercial |
$8,258.60
|
| Rate for Payer: Humana KY Medicaid |
$3,341.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3,375.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,967.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,170.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,914.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,408.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,550.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,287.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,772.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,452.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,704.04
|
| Rate for Payer: PHCS Commercial |
$9,327.36
|
| Rate for Payer: United Healthcare All Payer |
$8,550.08
|
|
|
GPS III DBLE KIT W/30ML ACDA
|
Facility
|
IP
|
$9,716.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,914.80 |
| Max. Negotiated Rate |
$9,327.36 |
| Rate for Payer: Aetna Commercial |
$7,481.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,578.48
|
| Rate for Payer: Cash Price |
$4,858.00
|
| Rate for Payer: Cigna Commercial |
$8,064.28
|
| Rate for Payer: First Health Commercial |
$9,230.20
|
| Rate for Payer: Humana Commercial |
$8,258.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,967.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,170.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,914.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,550.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,287.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,772.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,452.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,704.04
|
| Rate for Payer: PHCS Commercial |
$9,327.36
|
| Rate for Payer: United Healthcare All Payer |
$8,550.08
|
|
|
GPS III MINI KIT W/30ML ACDA
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
GPS III MINI KIT W/30ML ACDA
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
GPS III SINGLE KIT W/30ML ACDA
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
GPS III SINGLE KIT W/30ML ACDA
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
GPSIII SPARE BUCKT KIT 60ML GR
|
Facility
|
IP
|
$1,877.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$563.28 |
| Max. Negotiated Rate |
$1,802.50 |
| Rate for Payer: Aetna Commercial |
$1,445.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,464.53
|
| Rate for Payer: Cash Price |
$938.80
|
| Rate for Payer: Cigna Commercial |
$1,558.41
|
| Rate for Payer: First Health Commercial |
$1,783.72
|
| Rate for Payer: Humana Commercial |
$1,595.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,539.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,385.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,652.29
|
| Rate for Payer: Ohio Health Group HMO |
$1,408.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,502.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,633.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.54
|
| Rate for Payer: PHCS Commercial |
$1,802.50
|
| Rate for Payer: United Healthcare All Payer |
$1,652.29
|
|
|
GPSIII SPARE BUCKT KIT 60ML GR
|
Facility
|
OP
|
$1,877.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$563.28 |
| Max. Negotiated Rate |
$1,802.50 |
| Rate for Payer: Aetna Commercial |
$1,445.75
|
| Rate for Payer: Anthem Medicaid |
$645.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,464.53
|
| Rate for Payer: Cash Price |
$938.80
|
| Rate for Payer: Cigna Commercial |
$1,558.41
|
| Rate for Payer: First Health Commercial |
$1,783.72
|
| Rate for Payer: Humana Commercial |
$1,595.96
|
| Rate for Payer: Humana KY Medicaid |
$645.71
|
| Rate for Payer: Kentucky WC Medicaid |
$652.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,539.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,385.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$563.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$658.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,652.29
|
| Rate for Payer: Ohio Health Group HMO |
$1,408.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,502.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,633.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.54
|
| Rate for Payer: PHCS Commercial |
$1,802.50
|
| Rate for Payer: United Healthcare All Payer |
$1,652.29
|
|
|
GRACILIS
|
Facility
|
OP
|
$7,471.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,241.38 |
| Max. Negotiated Rate |
$7,172.40 |
| Rate for Payer: Aetna Commercial |
$5,752.86
|
| Rate for Payer: Anthem Medicaid |
$2,569.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,827.57
|
| Rate for Payer: Cash Price |
$3,735.62
|
| Rate for Payer: Cigna Commercial |
$6,201.14
|
| Rate for Payer: First Health Commercial |
$7,097.69
|
| Rate for Payer: Humana Commercial |
$6,350.56
|
| Rate for Payer: Humana KY Medicaid |
$2,569.36
|
| Rate for Payer: Kentucky WC Medicaid |
$2,595.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,126.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,513.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,241.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,620.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,574.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,603.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,977.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,499.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,155.16
|
| Rate for Payer: PHCS Commercial |
$7,172.40
|
| Rate for Payer: United Healthcare All Payer |
$6,574.70
|
|
|
GRACILIS
|
Facility
|
IP
|
$7,471.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,241.38 |
| Max. Negotiated Rate |
$7,172.40 |
| Rate for Payer: Aetna Commercial |
$5,752.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,827.57
|
| Rate for Payer: Cash Price |
$3,735.62
|
| Rate for Payer: Cigna Commercial |
$6,201.14
|
| Rate for Payer: First Health Commercial |
$7,097.69
|
| Rate for Payer: Humana Commercial |
$6,350.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,126.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,513.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,241.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,574.70
|
| Rate for Payer: Ohio Health Group HMO |
$5,603.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,977.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,499.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,155.16
|
| Rate for Payer: PHCS Commercial |
$7,172.40
|
| Rate for Payer: United Healthcare All Payer |
$6,574.70
|
|
|
GRAFIX PL 2CM X 3CM
|
Facility
|
OP
|
$6,814.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,044.28 |
| Max. Negotiated Rate |
$6,541.68 |
| Rate for Payer: Aetna Commercial |
$5,246.97
|
| Rate for Payer: Anthem Medicaid |
$2,343.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.11
|
| Rate for Payer: Cash Price |
$3,407.12
|
| Rate for Payer: Cigna Commercial |
$5,655.83
|
| Rate for Payer: First Health Commercial |
$6,473.54
|
| Rate for Payer: Humana Commercial |
$5,792.11
|
| Rate for Payer: Humana KY Medicaid |
$2,343.42
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,587.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,028.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,996.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,110.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,451.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,928.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,701.83
|
| Rate for Payer: PHCS Commercial |
$6,541.68
|
| Rate for Payer: United Healthcare All Payer |
$5,996.54
|
|
|
GRAFIX PL 2CM X 3CM
|
Facility
|
IP
|
$6,814.25
|
|
|
Service Code
|
HCPCS Q4133
|
| Hospital Charge Code |
27000274
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,044.28 |
| Max. Negotiated Rate |
$6,541.68 |
| Rate for Payer: Aetna Commercial |
$5,246.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.11
|
| Rate for Payer: Cash Price |
$3,407.12
|
| Rate for Payer: Cigna Commercial |
$5,655.83
|
| Rate for Payer: First Health Commercial |
$6,473.54
|
| Rate for Payer: Humana Commercial |
$5,792.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,587.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,028.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,996.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,110.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,451.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,928.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,701.83
|
| Rate for Payer: PHCS Commercial |
$6,541.68
|
| Rate for Payer: United Healthcare All Payer |
$5,996.54
|
|
|
GRAFT 4-7MM*40CM TAPER TS
|
Facility
|
OP
|
$3,755.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.50 |
| Max. Negotiated Rate |
$3,604.80 |
| Rate for Payer: Aetna Commercial |
$2,891.35
|
| Rate for Payer: Anthem Medicaid |
$1,291.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,928.90
|
| Rate for Payer: Cash Price |
$1,877.50
|
| Rate for Payer: Cigna Commercial |
$3,116.65
|
| Rate for Payer: First Health Commercial |
$3,567.25
|
| Rate for Payer: Humana Commercial |
$3,191.75
|
| Rate for Payer: Humana KY Medicaid |
$1,291.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,304.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,079.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,771.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,126.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,317.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,304.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,816.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,266.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,590.95
|
| Rate for Payer: PHCS Commercial |
$3,604.80
|
| Rate for Payer: United Healthcare All Payer |
$3,304.40
|
|
|
GRAFT 4-7MM*40CM TAPER TS
|
Facility
|
IP
|
$3,755.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,126.50 |
| Max. Negotiated Rate |
$3,604.80 |
| Rate for Payer: Aetna Commercial |
$2,891.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,928.90
|
| Rate for Payer: Cash Price |
$1,877.50
|
| Rate for Payer: Cigna Commercial |
$3,116.65
|
| Rate for Payer: First Health Commercial |
$3,567.25
|
| Rate for Payer: Humana Commercial |
$3,191.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,079.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,771.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,126.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,304.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,816.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,004.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,266.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,590.95
|
| Rate for Payer: PHCS Commercial |
$3,604.80
|
| Rate for Payer: United Healthcare All Payer |
$3,304.40
|
|
