|
GRAFT Z PROX ZTEG-2P-42-216-US
|
Facility
|
IP
|
$72,820.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,846.00 |
| Max. Negotiated Rate |
$69,907.20 |
| Rate for Payer: Aetna Commercial |
$56,071.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$56,799.60
|
| Rate for Payer: Cash Price |
$36,410.00
|
| Rate for Payer: Cigna Commercial |
$60,440.60
|
| Rate for Payer: First Health Commercial |
$69,179.00
|
| Rate for Payer: Humana Commercial |
$61,897.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59,712.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53,741.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,846.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$64,081.60
|
| Rate for Payer: Ohio Health Group HMO |
$54,615.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$58,256.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63,353.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50,245.80
|
| Rate for Payer: PHCS Commercial |
$69,907.20
|
| Rate for Payer: United Healthcare All Payer |
$64,081.60
|
|
|
GRAFT Z RENU ANC AX1-1-36-116
|
Facility
|
OP
|
$30,158.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,047.62 |
| Max. Negotiated Rate |
$28,952.40 |
| Rate for Payer: Aetna Commercial |
$23,222.24
|
| Rate for Payer: Anthem Medicaid |
$10,371.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,523.83
|
| Rate for Payer: Cash Price |
$15,079.38
|
| Rate for Payer: Cigna Commercial |
$25,031.76
|
| Rate for Payer: First Health Commercial |
$28,650.81
|
| Rate for Payer: Humana Commercial |
$25,634.94
|
| Rate for Payer: Humana KY Medicaid |
$10,371.59
|
| Rate for Payer: Kentucky WC Medicaid |
$10,477.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,730.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,257.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,047.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,579.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,539.70
|
| Rate for Payer: Ohio Health Group HMO |
$22,619.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,127.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,238.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,809.54
|
| Rate for Payer: PHCS Commercial |
$28,952.40
|
| Rate for Payer: United Healthcare All Payer |
$26,539.70
|
|
|
GRAFT Z RENU ANC AX1-1-36-116
|
Facility
|
IP
|
$30,158.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,047.62 |
| Max. Negotiated Rate |
$28,952.40 |
| Rate for Payer: Aetna Commercial |
$23,222.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,523.83
|
| Rate for Payer: Cash Price |
$15,079.38
|
| Rate for Payer: Cigna Commercial |
$25,031.76
|
| Rate for Payer: First Health Commercial |
$28,650.81
|
| Rate for Payer: Humana Commercial |
$25,634.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,730.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,257.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,047.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,539.70
|
| Rate for Payer: Ohio Health Group HMO |
$22,619.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24,127.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26,238.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20,809.54
|
| Rate for Payer: PHCS Commercial |
$28,952.40
|
| Rate for Payer: United Healthcare All Payer |
$26,539.70
|
|
|
GRAFT Z RENU ANC AX1-2-22-113
|
Facility
|
IP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-22-113
|
Facility
|
OP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem Medicaid |
$9,876.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Humana KY Medicaid |
$9,876.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9,976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,074.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-24-113
|
Facility
|
IP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-24-113
|
Facility
|
OP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem Medicaid |
$9,876.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Humana KY Medicaid |
$9,876.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9,976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,074.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-28-113
|
Facility
|
IP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-28-113
|
Facility
|
OP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem Medicaid |
$9,876.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Humana KY Medicaid |
$9,876.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9,976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,074.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-30-113
|
Facility
|
OP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem Medicaid |
$9,876.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Humana KY Medicaid |
$9,876.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9,976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,074.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-30-113
|
Facility
|
IP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-32-113
|
Facility
|
OP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem Medicaid |
$9,876.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Humana KY Medicaid |
$9,876.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9,976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,074.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-32-113
|
Facility
|
IP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-36-127
|
Facility
|
IP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAFT Z RENU ANC AX1-2-36-127
|
Facility
|
OP
|
$28,718.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,615.62 |
| Max. Negotiated Rate |
$27,570.00 |
| Rate for Payer: Aetna Commercial |
$22,113.44
|
| Rate for Payer: Anthem Medicaid |
$9,876.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22,400.62
|
| Rate for Payer: Cash Price |
$14,359.38
|
| Rate for Payer: Cigna Commercial |
$23,836.56
|
| Rate for Payer: First Health Commercial |
$27,282.81
|
| Rate for Payer: Humana Commercial |
$24,410.94
|
| Rate for Payer: Humana KY Medicaid |
$9,876.38
|
| Rate for Payer: Kentucky WC Medicaid |
$9,976.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23,549.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21,194.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,615.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,074.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$25,272.50
|
| Rate for Payer: Ohio Health Group HMO |
$21,539.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22,975.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24,985.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19,815.94
|
| Rate for Payer: PHCS Commercial |
$27,570.00
|
| Rate for Payer: United Healthcare All Payer |
$25,272.50
|
|
|
GRAM STAIN / BV SCORE
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.18
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
GRAM STAIN / BV SCORE
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.56 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna Commercial |
$5.49
|
| Rate for Payer: Ambetter Exchange |
$4.27
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.12
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$6.12
|
| Rate for Payer: Healthspan PPO |
$4.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.27
|
| Rate for Payer: Multiplan PHCS |
$36.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.55
|
| Rate for Payer: UHCCP Medicaid |
$21.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$2.56
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.27
|
|
|
GRAM STAIN / BV SCORE
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 87205
|
| Hospital Charge Code |
30001324
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$4.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.98
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.27
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| 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 |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
GRAND SLAM PTCA GW 300CM .014
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
GRAND SLAM PTCA GW 300CM .014
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
GRANISETRON 0.1mg (1mg SDV)
|
Facility
|
IP
|
$54.50
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
25004376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$52.32 |
| Rate for Payer: Aetna Commercial |
$41.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$42.51
|
| Rate for Payer: Cash Price |
$27.25
|
| Rate for Payer: Cigna Commercial |
$45.23
|
| Rate for Payer: First Health Commercial |
$51.77
|
| Rate for Payer: Humana Commercial |
$46.33
|
| 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 |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.60
|
| Rate for Payer: PHCS Commercial |
$52.32
|
| Rate for Payer: United Healthcare All Payer |
$47.96
|
|
|
GRANISETRON 0.1mg (1mg SDV)
|
Facility
|
OP
|
$54.50
|
|
|
Service Code
|
HCPCS J1626
|
| Hospital Charge Code |
25004376
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.35 |
| Max. Negotiated Rate |
$52.32 |
| Rate for Payer: Aetna Commercial |
$41.97
|
| 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 |
$45.23
|
| Rate for Payer: First Health Commercial |
$51.77
|
| Rate for Payer: Humana Commercial |
$46.33
|
| 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 |
$43.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.60
|
| Rate for Payer: PHCS Commercial |
$52.32
|
| Rate for Payer: United Healthcare All Payer |
$47.96
|
|
|
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 |
$0.30 |
| 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 |
$0.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,062.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$0.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$0.41
|
| 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 |
$0.30
|
| 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 |
$0.36
|
| 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 |
$1,089.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,184.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$939.60
|
| 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
|
IP
|
$1,361.74
|
|
|
Service Code
|
HCPCS J1447
|
| Hospital Charge Code |
25002058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$408.52 |
| 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 |
$1,089.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,184.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$939.60
|
| 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 |
$653.82 |
| 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 |
$1,743.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,896.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,503.79
|
| Rate for Payer: PHCS Commercial |
$2,092.22
|
| Rate for Payer: United Healthcare All Payer |
$1,917.87
|
|
