|
IKARI 5FR LEFT 4.0
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR LEFT 4.0
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR LEFT 4.5
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR LEFT 4.5
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR RIGHT 1.0
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR RIGHT 1.0
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR RIGHT 1.5
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR RIGHT 1.5
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR RIGHT 2.0
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI 5FR RIGHT 2.0
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI TIG 4.0
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
IKARI TIG 4.0
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
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
|
|
|
ILEAL CONDUIT
|
Facility
|
OP
|
$4,200.00
|
|
|
Service Code
|
HCPCS 50820
|
| Hospital Charge Code |
76102058
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$546.00 |
| Max. Negotiated Rate |
$4,032.00 |
| Rate for Payer: Aetna Commercial |
$3,234.00
|
| Rate for Payer: Anthem Medicaid |
$1,444.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,276.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$3,486.00
|
| Rate for Payer: First Health Commercial |
$3,990.00
|
| Rate for Payer: Humana Commercial |
$3,570.00
|
| Rate for Payer: Humana KY Medicaid |
$1,444.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1,459.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,444.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,099.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,260.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,473.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,696.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$546.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,302.00
|
| Rate for Payer: PHCS Commercial |
$4,032.00
|
| Rate for Payer: United Healthcare All Payer |
$3,696.00
|
|
|
ILEAL CONDUIT
|
Professional
|
Both
|
$4,200.00
|
|
|
Service Code
|
HCPCS 50820
|
| Hospital Charge Code |
76102058
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,160.83 |
| Max. Negotiated Rate |
$4,200.00 |
| Rate for Payer: Aetna Commercial |
$2,135.84
|
| Rate for Payer: Anthem Medicaid |
$1,160.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,200.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$1,900.85
|
| Rate for Payer: Healthspan PPO |
$1,707.80
|
| Rate for Payer: Humana Medicaid |
$1,160.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,792.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,184.05
|
| Rate for Payer: Molina Healthcare Passport |
$1,160.83
|
| Rate for Payer: Multiplan PHCS |
$2,520.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,940.00
|
| Rate for Payer: UHCCP Medicaid |
$1,470.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,172.44
|
|
|
ILEAL CONDUIT
|
Facility
|
IP
|
$4,200.00
|
|
|
Service Code
|
HCPCS 50820
|
| Hospital Charge Code |
76102058
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$546.00 |
| Max. Negotiated Rate |
$4,032.00 |
| Rate for Payer: Aetna Commercial |
$3,234.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,276.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$3,486.00
|
| Rate for Payer: First Health Commercial |
$3,990.00
|
| Rate for Payer: Humana Commercial |
$3,570.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,444.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,099.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,696.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$546.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,302.00
|
| Rate for Payer: PHCS Commercial |
$4,032.00
|
| Rate for Payer: United Healthcare All Payer |
$3,696.00
|
|
|
ILEAL CONDUIT(P
|
Professional
|
Both
|
$4,200.00
|
|
|
Service Code
|
HCPCS 50820
|
| Hospital Charge Code |
761P2058
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,160.83 |
| Max. Negotiated Rate |
$4,200.00 |
| Rate for Payer: Aetna Commercial |
$2,135.84
|
| Rate for Payer: Anthem Medicaid |
$1,160.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,200.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$1,900.85
|
| Rate for Payer: Healthspan PPO |
$1,707.80
|
| Rate for Payer: Humana Medicaid |
$1,160.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,792.14
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,184.05
|
| Rate for Payer: Molina Healthcare Passport |
$1,160.83
|
| Rate for Payer: Multiplan PHCS |
$2,520.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,940.00
|
| Rate for Payer: UHCCP Medicaid |
$1,470.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,172.44
|
|
|
ILEOSTOMY
|
Facility
|
OP
|
$2,340.00
|
|
|
Service Code
|
HCPCS 44144
|
| Hospital Charge Code |
76101817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$304.20 |
| Max. Negotiated Rate |
$2,246.40 |
| Rate for Payer: Aetna Commercial |
$1,801.80
|
| Rate for Payer: Anthem Medicaid |
$804.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,825.20
|
| Rate for Payer: Cash Price |
$1,170.00
|
| Rate for Payer: Cigna Commercial |
$1,942.20
|
| Rate for Payer: First Health Commercial |
$2,223.00
|
| Rate for Payer: Humana Commercial |
$1,989.00
|
| Rate for Payer: Humana KY Medicaid |
$804.73
|
| Rate for Payer: Kentucky WC Medicaid |
$812.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,918.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,726.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$702.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$820.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,059.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,755.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$304.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$725.40
|
| Rate for Payer: PHCS Commercial |
$2,246.40
|
| Rate for Payer: United Healthcare All Payer |
$2,059.20
|
|
|
ILEOSTOMY
|
Facility
|
IP
|
$2,340.00
|
|
|
Service Code
|
HCPCS 44144
|
| Hospital Charge Code |
76101817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$304.20 |
| Max. Negotiated Rate |
$2,246.40 |
| Rate for Payer: Aetna Commercial |
$1,801.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,825.20
|
| Rate for Payer: Cash Price |
$1,170.00
|
| Rate for Payer: Cigna Commercial |
$1,942.20
|
| Rate for Payer: First Health Commercial |
$2,223.00
|
| Rate for Payer: Humana Commercial |
$1,989.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,918.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,726.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$702.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,059.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,755.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$304.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$725.40
|
| Rate for Payer: PHCS Commercial |
$2,246.40
|
| Rate for Payer: United Healthcare All Payer |
$2,059.20
|
|
|
ILEOSTOMY
|
Professional
|
Both
|
$2,340.00
|
|
|
Service Code
|
HCPCS 44144
|
| Hospital Charge Code |
76101817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$819.00 |
| Max. Negotiated Rate |
$2,495.90 |
| Rate for Payer: Aetna Commercial |
$2,495.90
|
| Rate for Payer: Anthem Medicaid |
$825.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,170.00
|
| Rate for Payer: Cash Price |
$1,170.00
|
| Rate for Payer: Cigna Commercial |
$2,286.79
|
| Rate for Payer: Healthspan PPO |
$2,104.84
|
| Rate for Payer: Humana Medicaid |
$825.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,253.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$841.60
|
| Rate for Payer: Molina Healthcare Passport |
$825.10
|
| Rate for Payer: Multiplan PHCS |
$1,404.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,638.00
|
| Rate for Payer: UHCCP Medicaid |
$819.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$833.35
|
|
|
ILEOSTOMY
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44310
|
| Hospital Charge Code |
76101836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$547.18 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna Commercial |
$1,509.94
|
| Rate for Payer: Anthem Medicaid |
$547.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,850.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,407.07
|
| Rate for Payer: Healthspan PPO |
$1,273.36
|
| Rate for Payer: Humana Medicaid |
$547.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,330.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$558.12
|
| Rate for Payer: Molina Healthcare Passport |
$547.18
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,295.00
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$552.65
|
|
|
ILEOSTOMY
|
Facility
|
OP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44310
|
| Hospital Charge Code |
76101836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.50 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem Medicaid |
$636.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Humana KY Medicaid |
$636.22
|
| Rate for Payer: Kentucky WC Medicaid |
$642.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$648.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$370.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
ILEOSTOMY
|
Facility
|
IP
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44310
|
| Hospital Charge Code |
76101836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.50 |
| Max. Negotiated Rate |
$1,776.00 |
| Rate for Payer: Aetna Commercial |
$1,424.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,443.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,535.50
|
| Rate for Payer: First Health Commercial |
$1,757.50
|
| Rate for Payer: Humana Commercial |
$1,572.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,517.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,365.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,628.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,387.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$370.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$240.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$573.50
|
| Rate for Payer: PHCS Commercial |
$1,776.00
|
| Rate for Payer: United Healthcare All Payer |
$1,628.00
|
|
|
ILEOSTOMY(P
|
Professional
|
Both
|
$2,340.00
|
|
|
Service Code
|
HCPCS 44144
|
| Hospital Charge Code |
761P1817
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$819.00 |
| Max. Negotiated Rate |
$2,495.90 |
| Rate for Payer: Aetna Commercial |
$2,495.90
|
| Rate for Payer: Anthem Medicaid |
$825.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,170.00
|
| Rate for Payer: Cash Price |
$1,170.00
|
| Rate for Payer: Cigna Commercial |
$2,286.79
|
| Rate for Payer: Healthspan PPO |
$2,104.84
|
| Rate for Payer: Humana Medicaid |
$825.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,253.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$841.60
|
| Rate for Payer: Molina Healthcare Passport |
$825.10
|
| Rate for Payer: Multiplan PHCS |
$1,404.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,638.00
|
| Rate for Payer: UHCCP Medicaid |
$819.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$833.35
|
|
|
ILEOSTOMY(P
|
Professional
|
Both
|
$1,850.00
|
|
|
Service Code
|
HCPCS 44310
|
| Hospital Charge Code |
761P1836
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$547.18 |
| Max. Negotiated Rate |
$1,850.00 |
| Rate for Payer: Aetna Commercial |
$1,509.94
|
| Rate for Payer: Anthem Medicaid |
$547.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,850.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cash Price |
$925.00
|
| Rate for Payer: Cigna Commercial |
$1,407.07
|
| Rate for Payer: Healthspan PPO |
$1,273.36
|
| Rate for Payer: Humana Medicaid |
$547.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,330.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$558.12
|
| Rate for Payer: Molina Healthcare Passport |
$547.18
|
| Rate for Payer: Multiplan PHCS |
$1,110.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,295.00
|
| Rate for Payer: UHCCP Medicaid |
$647.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$552.65
|
|
|
ILIAC REVASC
|
Professional
|
Both
|
$15,768.33
|
|
|
Service Code
|
HCPCS 37220
|
| Hospital Charge Code |
76101544
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$214.75 |
| Max. Negotiated Rate |
$15,768.33 |
| Rate for Payer: Aetna Commercial |
$712.86
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$214.75
|
| Rate for Payer: Anthem Medicaid |
$380.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$15,768.33
|
| Rate for Payer: Cash Price |
$7,884.16
|
| Rate for Payer: Cash Price |
$7,884.16
|
| Rate for Payer: Cigna Commercial |
$806.91
|
| Rate for Payer: Healthspan PPO |
$2,965.58
|
| Rate for Payer: Humana Medicaid |
$380.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$555.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$388.58
|
| Rate for Payer: Molina Healthcare Passport |
$380.96
|
| Rate for Payer: Multiplan PHCS |
$9,461.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11,037.83
|
| Rate for Payer: UHCCP Medicaid |
$225.49
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$384.77
|
|
