|
ILIAC REVASC W/STENT(P
|
Professional
|
Both
|
$4,800.00
|
|
|
Service Code
|
HCPCS 37221
|
| Hospital Charge Code |
761P1545
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$260.88 |
| Max. Negotiated Rate |
$4,374.50 |
| Rate for Payer: Aetna Commercial |
$865.31
|
| Rate for Payer: Ambetter Exchange |
$460.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$260.88
|
| Rate for Payer: Anthem Medicaid |
$4,092.38
|
| Rate for Payer: Buckeye Individual/Medicaid |
$460.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$460.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$552.29
|
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Cash Price |
$2,400.00
|
| Rate for Payer: Cigna Commercial |
$981.73
|
| Rate for Payer: Healthspan PPO |
$4,374.50
|
| Rate for Payer: Humana Medicaid |
$4,092.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$674.54
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$460.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$460.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$4,174.23
|
| Rate for Payer: Molina Healthcare Passport |
$4,092.38
|
| Rate for Payer: Multiplan PHCS |
$2,880.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$598.31
|
| Rate for Payer: UHCCP Medicaid |
$273.92
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$4,133.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$460.24
|
|
|
ILIAC REVASC W/STENT(T
|
Facility
|
IP
|
$18,268.00
|
|
|
Service Code
|
HCPCS 37221
|
| Hospital Charge Code |
761T1545
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$5,480.40 |
| Max. Negotiated Rate |
$17,537.28 |
| Rate for Payer: Aetna Commercial |
$14,066.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,249.04
|
| Rate for Payer: Cash Price |
$9,134.00
|
| Rate for Payer: Cigna Commercial |
$15,162.44
|
| Rate for Payer: First Health Commercial |
$17,354.60
|
| Rate for Payer: Humana Commercial |
$15,527.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,979.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,481.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,480.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,075.84
|
| Rate for Payer: Ohio Health Group HMO |
$13,701.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,893.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,604.92
|
| Rate for Payer: PHCS Commercial |
$17,537.28
|
| Rate for Payer: United Healthcare All Payer |
$16,075.84
|
|
|
ILIAC REVASC W/STENT(T
|
Facility
|
OP
|
$18,268.00
|
|
|
Service Code
|
HCPCS 37221
|
| Hospital Charge Code |
761T1545
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$6,282.37 |
| Max. Negotiated Rate |
$17,537.28 |
| Rate for Payer: Aetna Commercial |
$14,066.36
|
| Rate for Payer: Anthem Medicaid |
$6,282.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10,478.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,249.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14,669.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$14,145.92
|
| Rate for Payer: Cash Price |
$9,134.00
|
| Rate for Payer: Cash Price |
$9,134.00
|
| Rate for Payer: Cigna Commercial |
$15,162.44
|
| Rate for Payer: First Health Commercial |
$17,354.60
|
| Rate for Payer: Humana Commercial |
$15,527.80
|
| Rate for Payer: Humana KY Medicaid |
$6,282.37
|
| Rate for Payer: Humana Medicare Advantage |
$10,478.46
|
| Rate for Payer: Kentucky WC Medicaid |
$6,346.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,979.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,481.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,574.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,408.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,075.84
|
| Rate for Payer: Ohio Health Group HMO |
$13,701.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,614.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,893.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,604.92
|
| Rate for Payer: PHCS Commercial |
$17,537.28
|
| Rate for Payer: United Healthcare All Payer |
$16,075.84
|
|
|
ILIOINGUINAL NERVE BLOCK
|
Facility
|
IP
|
$1,486.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
76102316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$445.80 |
| Max. Negotiated Rate |
$1,426.56 |
| Rate for Payer: Aetna Commercial |
$1,144.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,159.08
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$1,233.38
|
| Rate for Payer: First Health Commercial |
$1,411.70
|
| Rate for Payer: Humana Commercial |
$1,263.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,218.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,096.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$445.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,307.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,114.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,292.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.34
|
| Rate for Payer: PHCS Commercial |
$1,426.56
|
| Rate for Payer: United Healthcare All Payer |
$1,307.68
|
|
|
ILIOINGUINAL NERVE BLOCK
|
Professional
|
Both
|
$1,486.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
76102316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$891.60 |
| Rate for Payer: Aetna Commercial |
$150.91
|
| Rate for Payer: Ambetter Exchange |
$51.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.21
|
| Rate for Payer: Anthem Medicaid |
$85.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$51.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$51.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$61.57
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Healthspan PPO |
$156.19
|
| Rate for Payer: Humana Medicaid |
$85.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$120.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$51.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$87.59
|
| Rate for Payer: Molina Healthcare Passport |
$85.87
|
| Rate for Payer: Multiplan PHCS |
$891.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.70
|
| Rate for Payer: UHCCP Medicaid |
$43.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$86.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$51.31
|
|
|
ILIOINGUINAL NERVE BLOCK
|
Facility
|
OP
|
$1,486.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
76102316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$511.04 |
| Max. Negotiated Rate |
$1,426.56 |
| Rate for Payer: Aetna Commercial |
$1,144.22
|
| Rate for Payer: Anthem Medicaid |
$511.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,159.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cash Price |
$743.00
|
| Rate for Payer: Cigna Commercial |
$1,233.38
|
| Rate for Payer: First Health Commercial |
$1,411.70
|
| Rate for Payer: Humana Commercial |
$1,263.10
|
| Rate for Payer: Humana KY Medicaid |
$511.04
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$516.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,218.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,096.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$521.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,307.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,114.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,292.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,025.34
|
| Rate for Payer: PHCS Commercial |
$1,426.56
|
| Rate for Payer: United Healthcare All Payer |
$1,307.68
|
|
|
ILIOINGUINAL NERVE BLOCK(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
761P2316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$194.75 |
| Rate for Payer: Aetna Commercial |
$150.91
|
| Rate for Payer: Ambetter Exchange |
$51.31
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.21
|
| Rate for Payer: Anthem Medicaid |
$85.87
|
| Rate for Payer: Buckeye Individual/Medicaid |
$51.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$51.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$61.57
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$194.75
|
| Rate for Payer: Healthspan PPO |
$156.19
|
| Rate for Payer: Humana Medicaid |
$85.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$120.72
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$51.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$51.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$87.59
|
| Rate for Payer: Molina Healthcare Passport |
$85.87
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$66.70
|
| Rate for Payer: UHCCP Medicaid |
$43.27
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$86.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$51.31
|
|
|
ILIOINGUINAL NERVE BLOCK(T
|
Facility
|
IP
|
$1,236.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
761T2316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$370.80 |
| Max. Negotiated Rate |
$1,186.56 |
| Rate for Payer: Aetna Commercial |
$951.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$964.08
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cigna Commercial |
$1,025.88
|
| Rate for Payer: First Health Commercial |
$1,174.20
|
| Rate for Payer: Humana Commercial |
$1,050.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,013.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$912.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,087.68
|
| Rate for Payer: Ohio Health Group HMO |
$927.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.84
|
| Rate for Payer: PHCS Commercial |
$1,186.56
|
| Rate for Payer: United Healthcare All Payer |
$1,087.68
|
|
|
ILIOINGUINAL NERVE BLOCK(T
|
Facility
|
OP
|
$1,236.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
761T2316
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$425.06 |
| Max. Negotiated Rate |
$1,186.56 |
| Rate for Payer: Aetna Commercial |
$951.72
|
| Rate for Payer: Anthem Medicaid |
$425.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$639.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$964.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$895.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.82
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cash Price |
$618.00
|
| Rate for Payer: Cigna Commercial |
$1,025.88
|
| Rate for Payer: First Health Commercial |
$1,174.20
|
| Rate for Payer: Humana Commercial |
$1,050.60
|
| Rate for Payer: Humana KY Medicaid |
$425.06
|
| Rate for Payer: Humana Medicare Advantage |
$639.87
|
| Rate for Payer: Kentucky WC Medicaid |
$429.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,013.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$912.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$767.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$433.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,087.68
|
| Rate for Payer: Ohio Health Group HMO |
$927.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$852.84
|
| Rate for Payer: PHCS Commercial |
$1,186.56
|
| Rate for Payer: United Healthcare All Payer |
$1,087.68
|
|
|
ILIVIA 7 VR-T DF-1 PRO MRI
|
Facility
|
OP
|
$74,340.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,302.00 |
| Max. Negotiated Rate |
$71,366.40 |
| Rate for Payer: Aetna Commercial |
$57,241.80
|
| Rate for Payer: Anthem Medicaid |
$25,565.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,985.20
|
| Rate for Payer: Cash Price |
$37,170.00
|
| Rate for Payer: Cigna Commercial |
$61,702.20
|
| Rate for Payer: First Health Commercial |
$70,623.00
|
| Rate for Payer: Humana Commercial |
$63,189.00
|
| Rate for Payer: Humana KY Medicaid |
$25,565.53
|
| Rate for Payer: Kentucky WC Medicaid |
$25,825.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,958.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,862.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,302.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,078.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,419.20
|
| Rate for Payer: Ohio Health Group HMO |
$55,755.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,472.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,675.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,294.60
|
| Rate for Payer: PHCS Commercial |
$71,366.40
|
| Rate for Payer: United Healthcare All Payer |
$65,419.20
|
|
|
ILIVIA 7 VR-T DF-1 PRO MRI
|
Facility
|
IP
|
$74,340.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,302.00 |
| Max. Negotiated Rate |
$71,366.40 |
| Rate for Payer: Aetna Commercial |
$57,241.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57,985.20
|
| Rate for Payer: Cash Price |
$37,170.00
|
| Rate for Payer: Cigna Commercial |
$61,702.20
|
| Rate for Payer: First Health Commercial |
$70,623.00
|
| Rate for Payer: Humana Commercial |
$63,189.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$60,958.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$54,862.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,302.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,419.20
|
| Rate for Payer: Ohio Health Group HMO |
$55,755.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59,472.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$64,675.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$51,294.60
|
| Rate for Payer: PHCS Commercial |
$71,366.40
|
| Rate for Payer: United Healthcare All Payer |
$65,419.20
|
|
|
ILIVIA NEO 7 DR-T
|
Facility
|
OP
|
$36,837.50
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$11,051.25 |
| Max. Negotiated Rate |
$35,364.00 |
| Rate for Payer: Aetna Commercial |
$28,364.88
|
| Rate for Payer: Anthem Medicaid |
$12,668.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,733.25
|
| Rate for Payer: Cash Price |
$18,418.75
|
| Rate for Payer: Cigna Commercial |
$30,575.12
|
| Rate for Payer: First Health Commercial |
$34,995.62
|
| Rate for Payer: Humana Commercial |
$31,311.88
|
| Rate for Payer: Humana KY Medicaid |
$12,668.42
|
| Rate for Payer: Kentucky WC Medicaid |
$12,797.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,206.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,186.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,051.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$12,922.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$32,417.00
|
| Rate for Payer: Ohio Health Group HMO |
$27,628.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29,470.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32,048.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,417.88
|
| Rate for Payer: PHCS Commercial |
$35,364.00
|
| Rate for Payer: United Healthcare All Payer |
$32,417.00
|
|
|
ILIVIA NEO 7 DR-T
|
Facility
|
IP
|
$36,837.50
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$11,051.25 |
| Max. Negotiated Rate |
$35,364.00 |
| Rate for Payer: Aetna Commercial |
$28,364.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$28,733.25
|
| Rate for Payer: Cash Price |
$18,418.75
|
| Rate for Payer: Cigna Commercial |
$30,575.12
|
| Rate for Payer: First Health Commercial |
$34,995.62
|
| Rate for Payer: Humana Commercial |
$31,311.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$30,206.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$27,186.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,051.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$32,417.00
|
| Rate for Payer: Ohio Health Group HMO |
$27,628.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$29,470.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$32,048.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,417.88
|
| Rate for Payer: PHCS Commercial |
$35,364.00
|
| Rate for Payer: United Healthcare All Payer |
$32,417.00
|
|
|
ILIZAROV DISCLIP WIRE
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna Commercial |
$30.03
|
| Rate for Payer: Anthem Medicaid |
$13.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.42
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$32.37
|
| Rate for Payer: First Health Commercial |
$37.05
|
| Rate for Payer: Humana Commercial |
$33.15
|
| Rate for Payer: Humana KY Medicaid |
$13.41
|
| Rate for Payer: Kentucky WC Medicaid |
$13.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.32
|
| Rate for Payer: Ohio Health Group HMO |
$29.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.91
|
| Rate for Payer: PHCS Commercial |
$37.44
|
| Rate for Payer: United Healthcare All Payer |
$34.32
|
|
|
ILIZAROV DISCLIP WIRE
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$37.44 |
| Rate for Payer: Aetna Commercial |
$30.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.42
|
| Rate for Payer: Cash Price |
$19.50
|
| Rate for Payer: Cigna Commercial |
$32.37
|
| Rate for Payer: First Health Commercial |
$37.05
|
| Rate for Payer: Humana Commercial |
$33.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.32
|
| Rate for Payer: Ohio Health Group HMO |
$29.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.91
|
| Rate for Payer: PHCS Commercial |
$37.44
|
| Rate for Payer: United Healthcare All Payer |
$34.32
|
|
|
ILUMYA 1mg (100mg PFS)
|
Facility
|
IP
|
$97,889.85
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
25004213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29,366.96 |
| Max. Negotiated Rate |
$93,974.26 |
| Rate for Payer: Aetna Commercial |
$75,375.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76,354.08
|
| Rate for Payer: Cash Price |
$48,944.93
|
| Rate for Payer: Cigna Commercial |
$81,248.58
|
| Rate for Payer: First Health Commercial |
$92,995.36
|
| Rate for Payer: Humana Commercial |
$83,206.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80,269.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72,242.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29,366.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$86,143.07
|
| Rate for Payer: Ohio Health Group HMO |
$73,417.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78,311.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85,164.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,544.00
|
| Rate for Payer: PHCS Commercial |
$93,974.26
|
| Rate for Payer: United Healthcare All Payer |
$86,143.07
|
|
|
ILUMYA 1mg (100mg PFS)
|
Facility
|
OP
|
$97,889.85
|
|
|
Service Code
|
HCPCS J3245
|
| Hospital Charge Code |
25004213
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$126.24 |
| Max. Negotiated Rate |
$93,974.26 |
| Rate for Payer: Aetna Commercial |
$75,375.18
|
| Rate for Payer: Anthem Medicaid |
$33,664.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$126.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76,354.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$176.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$170.42
|
| Rate for Payer: Cash Price |
$48,944.93
|
| Rate for Payer: Cash Price |
$48,944.93
|
| Rate for Payer: Cigna Commercial |
$81,248.58
|
| Rate for Payer: First Health Commercial |
$92,995.36
|
| Rate for Payer: Humana Commercial |
$83,206.37
|
| Rate for Payer: Humana KY Medicaid |
$33,664.32
|
| Rate for Payer: Humana Medicare Advantage |
$126.24
|
| Rate for Payer: Kentucky WC Medicaid |
$34,006.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80,269.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72,242.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$151.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$34,339.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$86,143.07
|
| Rate for Payer: Ohio Health Group HMO |
$73,417.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78,311.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85,164.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,544.00
|
| Rate for Payer: PHCS Commercial |
$93,974.26
|
| Rate for Payer: United Healthcare All Payer |
$86,143.07
|
|
|
IM ADMIN EACH ADDL COMPONENT
|
Facility
|
OP
|
$31.00
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
77000007
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$29.76 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Anthem Medicaid |
$10.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.18
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$25.73
|
| Rate for Payer: First Health Commercial |
$29.45
|
| Rate for Payer: Humana Commercial |
$26.35
|
| Rate for Payer: Humana KY Medicaid |
$10.66
|
| Rate for Payer: Kentucky WC Medicaid |
$10.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.28
|
| Rate for Payer: Ohio Health Group HMO |
$23.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$29.76
|
| Rate for Payer: United Healthcare All Payer |
$27.28
|
|
|
IM ADMIN EACH ADDL COMPONENT
|
Facility
|
IP
|
$31.00
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
77000007
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$29.76 |
| Rate for Payer: Aetna Commercial |
$23.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.18
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$25.73
|
| Rate for Payer: First Health Commercial |
$29.45
|
| Rate for Payer: Humana Commercial |
$26.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.28
|
| Rate for Payer: Ohio Health Group HMO |
$23.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21.39
|
| Rate for Payer: PHCS Commercial |
$29.76
|
| Rate for Payer: United Healthcare All Payer |
$27.28
|
|
|
IM ADMIN EACH ADDL COMPONENT
|
Professional
|
Both
|
$31.00
|
|
|
Service Code
|
HCPCS 90461
|
| Hospital Charge Code |
77000007
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$18.77 |
| Rate for Payer: Ambetter Exchange |
$8.22
|
| Rate for Payer: Anthem Medicaid |
$18.40
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.86
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cash Price |
$15.50
|
| Rate for Payer: Cigna Commercial |
$16.84
|
| Rate for Payer: Healthspan PPO |
$10.25
|
| Rate for Payer: Humana Medicaid |
$18.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$15.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.77
|
| Rate for Payer: Molina Healthcare Passport |
$18.40
|
| Rate for Payer: Multiplan PHCS |
$18.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$10.69
|
| Rate for Payer: UHCCP Medicaid |
$10.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.58
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.22
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
OP
|
$2,122.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101995
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$729.76 |
| Max. Negotiated Rate |
$2,095.90 |
| Rate for Payer: Aetna Commercial |
$1,633.94
|
| Rate for Payer: Anthem Medicaid |
$729.76
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,655.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$1,061.00
|
| Rate for Payer: Cash Price |
$1,061.00
|
| Rate for Payer: Cigna Commercial |
$1,761.26
|
| Rate for Payer: First Health Commercial |
$2,015.90
|
| Rate for Payer: Humana Commercial |
$1,803.70
|
| Rate for Payer: Humana KY Medicaid |
$729.76
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$737.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,740.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,566.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$744.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,867.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,591.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,697.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,846.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.18
|
| Rate for Payer: PHCS Commercial |
$2,037.12
|
| Rate for Payer: United Healthcare All Payer |
$1,867.36
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Professional
|
Both
|
$4,423.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.26 |
| Max. Negotiated Rate |
$2,653.80 |
| Rate for Payer: Ambetter Exchange |
$181.65
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$165.26
|
| Rate for Payer: Anthem Medicaid |
$655.14
|
| Rate for Payer: Buckeye Individual/Medicaid |
$181.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$181.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$217.98
|
| Rate for Payer: Cash Price |
$2,211.50
|
| Rate for Payer: Cash Price |
$2,211.50
|
| Rate for Payer: Cigna Commercial |
$355.29
|
| Rate for Payer: Healthspan PPO |
$1,123.62
|
| Rate for Payer: Humana Medicaid |
$655.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$277.78
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$181.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$181.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$668.24
|
| Rate for Payer: Molina Healthcare Passport |
$655.14
|
| Rate for Payer: Multiplan PHCS |
$2,653.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$236.15
|
| Rate for Payer: UHCCP Medicaid |
$173.52
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$661.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$181.65
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
IP
|
$2,122.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101995
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$636.60 |
| Max. Negotiated Rate |
$2,037.12 |
| Rate for Payer: Aetna Commercial |
$1,633.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,655.16
|
| Rate for Payer: Cash Price |
$1,061.00
|
| Rate for Payer: Cigna Commercial |
$1,761.26
|
| Rate for Payer: First Health Commercial |
$2,015.90
|
| Rate for Payer: Humana Commercial |
$1,803.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,740.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,566.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$636.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,867.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,591.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,697.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,846.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.18
|
| Rate for Payer: PHCS Commercial |
$2,037.12
|
| Rate for Payer: United Healthcare All Payer |
$1,867.36
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
IP
|
$4,423.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,326.90 |
| Max. Negotiated Rate |
$4,246.08 |
| Rate for Payer: Aetna Commercial |
$3,405.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,449.94
|
| Rate for Payer: Cash Price |
$2,211.50
|
| Rate for Payer: Cigna Commercial |
$3,671.09
|
| Rate for Payer: First Health Commercial |
$4,201.85
|
| Rate for Payer: Humana Commercial |
$3,759.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,626.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,264.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,326.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,892.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,317.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,538.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,848.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,051.87
|
| Rate for Payer: PHCS Commercial |
$4,246.08
|
| Rate for Payer: United Healthcare All Payer |
$3,892.24
|
|
|
IMAGE CATH FLUID COLXN VISC
|
Facility
|
OP
|
$4,423.00
|
|
|
Service Code
|
HCPCS 49405
|
| Hospital Charge Code |
76101996
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,497.07 |
| Max. Negotiated Rate |
$4,246.08 |
| Rate for Payer: Aetna Commercial |
$3,405.71
|
| Rate for Payer: Anthem Medicaid |
$1,521.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,497.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,449.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,095.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,021.04
|
| Rate for Payer: Cash Price |
$2,211.50
|
| Rate for Payer: Cash Price |
$2,211.50
|
| Rate for Payer: Cigna Commercial |
$3,671.09
|
| Rate for Payer: First Health Commercial |
$4,201.85
|
| Rate for Payer: Humana Commercial |
$3,759.55
|
| Rate for Payer: Humana KY Medicaid |
$1,521.07
|
| Rate for Payer: Humana Medicare Advantage |
$1,497.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,536.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,626.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,264.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,796.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,551.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,892.24
|
| Rate for Payer: Ohio Health Group HMO |
$3,317.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,538.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,848.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,051.87
|
| Rate for Payer: PHCS Commercial |
$4,246.08
|
| Rate for Payer: United Healthcare All Payer |
$3,892.24
|
|
