|
INDIGO CATH 5
|
Facility
|
IP
|
$7,244.95
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,173.49 |
| Max. Negotiated Rate |
$6,955.15 |
| Rate for Payer: Aetna Commercial |
$5,578.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,651.06
|
| Rate for Payer: Cash Price |
$3,622.48
|
| Rate for Payer: Cigna Commercial |
$6,013.31
|
| Rate for Payer: First Health Commercial |
$6,882.70
|
| Rate for Payer: Humana Commercial |
$6,158.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,940.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,346.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,173.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,375.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,433.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,795.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,303.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.02
|
| Rate for Payer: PHCS Commercial |
$6,955.15
|
| Rate for Payer: United Healthcare All Payer |
$6,375.56
|
|
|
INDIGO CATH 6 ST 135CM
|
Facility
|
OP
|
$9,898.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,969.55 |
| Max. Negotiated Rate |
$9,502.56 |
| Rate for Payer: Aetna Commercial |
$7,621.85
|
| Rate for Payer: Anthem Medicaid |
$3,404.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,720.83
|
| Rate for Payer: Cash Price |
$4,949.25
|
| Rate for Payer: Cigna Commercial |
$8,215.75
|
| Rate for Payer: First Health Commercial |
$9,403.58
|
| Rate for Payer: Humana Commercial |
$8,413.73
|
| Rate for Payer: Humana KY Medicaid |
$3,404.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,438.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,116.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,305.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,969.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,472.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,710.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,423.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,918.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,611.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,829.97
|
| Rate for Payer: PHCS Commercial |
$9,502.56
|
| Rate for Payer: United Healthcare All Payer |
$8,710.68
|
|
|
INDIGO CATH 6 ST 135CM
|
Facility
|
IP
|
$9,898.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,969.55 |
| Max. Negotiated Rate |
$9,502.56 |
| Rate for Payer: Aetna Commercial |
$7,621.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,720.83
|
| Rate for Payer: Cash Price |
$4,949.25
|
| Rate for Payer: Cigna Commercial |
$8,215.75
|
| Rate for Payer: First Health Commercial |
$9,403.58
|
| Rate for Payer: Humana Commercial |
$8,413.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,116.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,305.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,969.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,710.68
|
| Rate for Payer: Ohio Health Group HMO |
$7,423.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,918.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,611.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,829.97
|
| Rate for Payer: PHCS Commercial |
$9,502.56
|
| Rate for Payer: United Healthcare All Payer |
$8,710.68
|
|
|
INDIGO CATH 7+ LIGHTNING
|
Facility
|
IP
|
$26,037.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,811.25 |
| Max. Negotiated Rate |
$24,996.00 |
| Rate for Payer: Aetna Commercial |
$20,048.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,309.25
|
| Rate for Payer: Cash Price |
$13,018.75
|
| Rate for Payer: Cigna Commercial |
$21,611.12
|
| Rate for Payer: First Health Commercial |
$24,735.62
|
| Rate for Payer: Humana Commercial |
$22,131.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,350.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,215.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,811.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,913.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,528.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,830.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,652.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,965.88
|
| Rate for Payer: PHCS Commercial |
$24,996.00
|
| Rate for Payer: United Healthcare All Payer |
$22,913.00
|
|
|
INDIGO CATH 7+ LIGHTNING
|
Facility
|
OP
|
$26,037.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,811.25 |
| Max. Negotiated Rate |
$24,996.00 |
| Rate for Payer: Aetna Commercial |
$20,048.88
|
| Rate for Payer: Anthem Medicaid |
$8,954.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,309.25
|
| Rate for Payer: Cash Price |
$13,018.75
|
| Rate for Payer: Cigna Commercial |
$21,611.12
|
| Rate for Payer: First Health Commercial |
$24,735.62
|
| Rate for Payer: Humana Commercial |
$22,131.88
|
| Rate for Payer: Humana KY Medicaid |
$8,954.30
|
| Rate for Payer: Kentucky WC Medicaid |
$9,045.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,350.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,215.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,811.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,133.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,913.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,528.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,830.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,652.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,965.88
|
| Rate for Payer: PHCS Commercial |
$24,996.00
|
| Rate for Payer: United Healthcare All Payer |
$22,913.00
|
|
|
INDIGO CATH 8+ LIGHTNING
|
Facility
|
IP
|
$26,787.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,036.25 |
| Max. Negotiated Rate |
$25,716.00 |
| Rate for Payer: Aetna Commercial |
$20,626.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,894.25
|
| Rate for Payer: Cash Price |
$13,393.75
|
| Rate for Payer: Cigna Commercial |
$22,233.62
|
| Rate for Payer: First Health Commercial |
$25,448.12
|
| Rate for Payer: Humana Commercial |
$22,769.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,965.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,769.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,036.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,573.00
|
| Rate for Payer: Ohio Health Group HMO |
$20,090.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,305.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,483.38
|
| Rate for Payer: PHCS Commercial |
$25,716.00
|
| Rate for Payer: United Healthcare All Payer |
$23,573.00
|
|
|
INDIGO CATH 8+ LIGHTNING
|
Facility
|
OP
|
$26,787.50
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,036.25 |
| Max. Negotiated Rate |
$25,716.00 |
| Rate for Payer: Aetna Commercial |
$20,626.38
|
| Rate for Payer: Anthem Medicaid |
$9,212.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,894.25
|
| Rate for Payer: Cash Price |
$13,393.75
|
| Rate for Payer: Cigna Commercial |
$22,233.62
|
| Rate for Payer: First Health Commercial |
$25,448.12
|
| Rate for Payer: Humana Commercial |
$22,769.38
|
| Rate for Payer: Humana KY Medicaid |
$9,212.22
|
| Rate for Payer: Kentucky WC Medicaid |
$9,305.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,965.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,769.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,036.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,397.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,573.00
|
| Rate for Payer: Ohio Health Group HMO |
$20,090.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,305.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,483.38
|
| Rate for Payer: PHCS Commercial |
$25,716.00
|
| Rate for Payer: United Healthcare All Payer |
$23,573.00
|
|
|
INDIGO CATH 8 ST 85CM
|
Facility
|
OP
|
$14,399.90
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,319.97 |
| Max. Negotiated Rate |
$13,823.90 |
| Rate for Payer: Aetna Commercial |
$11,087.92
|
| Rate for Payer: Anthem Medicaid |
$4,952.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,231.92
|
| Rate for Payer: Cash Price |
$7,199.95
|
| Rate for Payer: Cigna Commercial |
$11,951.92
|
| Rate for Payer: First Health Commercial |
$13,679.91
|
| Rate for Payer: Humana Commercial |
$12,239.92
|
| Rate for Payer: Humana KY Medicaid |
$4,952.13
|
| Rate for Payer: Kentucky WC Medicaid |
$5,002.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,807.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,627.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,319.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,051.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,671.91
|
| Rate for Payer: Ohio Health Group HMO |
$10,799.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,519.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,527.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,935.93
|
| Rate for Payer: PHCS Commercial |
$13,823.90
|
| Rate for Payer: United Healthcare All Payer |
$12,671.91
|
|
|
INDIGO CATH 8 ST 85CM
|
Facility
|
IP
|
$14,399.90
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,319.97 |
| Max. Negotiated Rate |
$13,823.90 |
| Rate for Payer: Aetna Commercial |
$11,087.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,231.92
|
| Rate for Payer: Cash Price |
$7,199.95
|
| Rate for Payer: Cigna Commercial |
$11,951.92
|
| Rate for Payer: First Health Commercial |
$13,679.91
|
| Rate for Payer: Humana Commercial |
$12,239.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,807.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,627.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,319.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,671.91
|
| Rate for Payer: Ohio Health Group HMO |
$10,799.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,519.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,527.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,935.93
|
| Rate for Payer: PHCS Commercial |
$13,823.90
|
| Rate for Payer: United Healthcare All Payer |
$12,671.91
|
|
|
INDIGO CATH 8 TORQ TIP 85CM
|
Facility
|
OP
|
$14,106.30
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,231.89 |
| Max. Negotiated Rate |
$13,542.05 |
| Rate for Payer: Aetna Commercial |
$10,861.85
|
| Rate for Payer: Anthem Medicaid |
$4,851.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,002.91
|
| Rate for Payer: Cash Price |
$7,053.15
|
| Rate for Payer: Cigna Commercial |
$11,708.23
|
| Rate for Payer: First Health Commercial |
$13,400.99
|
| Rate for Payer: Humana Commercial |
$11,990.35
|
| Rate for Payer: Humana KY Medicaid |
$4,851.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,900.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,567.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,410.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,231.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,948.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,413.54
|
| Rate for Payer: Ohio Health Group HMO |
$10,579.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,285.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,272.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,733.35
|
| Rate for Payer: PHCS Commercial |
$13,542.05
|
| Rate for Payer: United Healthcare All Payer |
$12,413.54
|
|
|
INDIGO CATH 8 TORQ TIP 85CM
|
Facility
|
IP
|
$14,106.30
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,231.89 |
| Max. Negotiated Rate |
$13,542.05 |
| Rate for Payer: Aetna Commercial |
$10,861.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,002.91
|
| Rate for Payer: Cash Price |
$7,053.15
|
| Rate for Payer: Cigna Commercial |
$11,708.23
|
| Rate for Payer: First Health Commercial |
$13,400.99
|
| Rate for Payer: Humana Commercial |
$11,990.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,567.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,410.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,231.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,413.54
|
| Rate for Payer: Ohio Health Group HMO |
$10,579.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,285.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,272.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,733.35
|
| Rate for Payer: PHCS Commercial |
$13,542.05
|
| Rate for Payer: United Healthcare All Payer |
$12,413.54
|
|
|
INDIGO CATH 8 XTORQ TIP 115CM
|
Facility
|
IP
|
$14,106.30
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,231.89 |
| Max. Negotiated Rate |
$13,542.05 |
| Rate for Payer: Aetna Commercial |
$10,861.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,002.91
|
| Rate for Payer: Cash Price |
$7,053.15
|
| Rate for Payer: Cigna Commercial |
$11,708.23
|
| Rate for Payer: First Health Commercial |
$13,400.99
|
| Rate for Payer: Humana Commercial |
$11,990.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,567.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,410.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,231.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,413.54
|
| Rate for Payer: Ohio Health Group HMO |
$10,579.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,285.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,272.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,733.35
|
| Rate for Payer: PHCS Commercial |
$13,542.05
|
| Rate for Payer: United Healthcare All Payer |
$12,413.54
|
|
|
INDIGO CATH 8 XTORQ TIP 115CM
|
Facility
|
OP
|
$14,106.30
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4,231.89 |
| Max. Negotiated Rate |
$13,542.05 |
| Rate for Payer: Aetna Commercial |
$10,861.85
|
| Rate for Payer: Anthem Medicaid |
$4,851.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,002.91
|
| Rate for Payer: Cash Price |
$7,053.15
|
| Rate for Payer: Cigna Commercial |
$11,708.23
|
| Rate for Payer: First Health Commercial |
$13,400.99
|
| Rate for Payer: Humana Commercial |
$11,990.35
|
| Rate for Payer: Humana KY Medicaid |
$4,851.16
|
| Rate for Payer: Kentucky WC Medicaid |
$4,900.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,567.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,410.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,231.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,948.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,413.54
|
| Rate for Payer: Ohio Health Group HMO |
$10,579.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,285.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,272.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,733.35
|
| Rate for Payer: PHCS Commercial |
$13,542.05
|
| Rate for Payer: United Healthcare All Payer |
$12,413.54
|
|
|
INDIGO SEPARATOR 6
|
Facility
|
OP
|
$6,942.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,082.60 |
| Max. Negotiated Rate |
$6,664.32 |
| Rate for Payer: Aetna Commercial |
$5,345.34
|
| Rate for Payer: Anthem Medicaid |
$2,387.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,414.76
|
| Rate for Payer: Cash Price |
$3,471.00
|
| Rate for Payer: Cigna Commercial |
$5,761.86
|
| Rate for Payer: First Health Commercial |
$6,594.90
|
| Rate for Payer: Humana Commercial |
$5,900.70
|
| Rate for Payer: Humana KY Medicaid |
$2,387.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,411.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,692.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,123.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,082.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,435.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,108.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,039.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,789.98
|
| Rate for Payer: PHCS Commercial |
$6,664.32
|
| Rate for Payer: United Healthcare All Payer |
$6,108.96
|
|
|
INDIGO SEPARATOR 6
|
Facility
|
IP
|
$6,942.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,082.60 |
| Max. Negotiated Rate |
$6,664.32 |
| Rate for Payer: Aetna Commercial |
$5,345.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,414.76
|
| Rate for Payer: Cash Price |
$3,471.00
|
| Rate for Payer: Cigna Commercial |
$5,761.86
|
| Rate for Payer: First Health Commercial |
$6,594.90
|
| Rate for Payer: Humana Commercial |
$5,900.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,692.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,123.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,082.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,108.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,206.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,553.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,039.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,789.98
|
| Rate for Payer: PHCS Commercial |
$6,664.32
|
| Rate for Payer: United Healthcare All Payer |
$6,108.96
|
|
|
INDIGO SEPARATOR 8
|
Facility
|
OP
|
$9,862.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,958.60 |
| Max. Negotiated Rate |
$9,467.52 |
| Rate for Payer: Aetna Commercial |
$7,593.74
|
| Rate for Payer: Anthem Medicaid |
$3,391.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,692.36
|
| Rate for Payer: Cash Price |
$4,931.00
|
| Rate for Payer: Cigna Commercial |
$8,185.46
|
| Rate for Payer: First Health Commercial |
$9,368.90
|
| Rate for Payer: Humana Commercial |
$8,382.70
|
| Rate for Payer: Humana KY Medicaid |
$3,391.54
|
| Rate for Payer: Kentucky WC Medicaid |
$3,426.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,086.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,278.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,958.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,459.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,678.56
|
| Rate for Payer: Ohio Health Group HMO |
$7,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,889.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,579.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,804.78
|
| Rate for Payer: PHCS Commercial |
$9,467.52
|
| Rate for Payer: United Healthcare All Payer |
$8,678.56
|
|
|
INDIGO SEPARATOR 8
|
Facility
|
IP
|
$9,862.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,958.60 |
| Max. Negotiated Rate |
$9,467.52 |
| Rate for Payer: Aetna Commercial |
$7,593.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,692.36
|
| Rate for Payer: Cash Price |
$4,931.00
|
| Rate for Payer: Cigna Commercial |
$8,185.46
|
| Rate for Payer: First Health Commercial |
$9,368.90
|
| Rate for Payer: Humana Commercial |
$8,382.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,086.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,278.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,958.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,678.56
|
| Rate for Payer: Ohio Health Group HMO |
$7,396.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,889.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,579.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,804.78
|
| Rate for Payer: PHCS Commercial |
$9,467.52
|
| Rate for Payer: United Healthcare All Payer |
$8,678.56
|
|
|
INDIRECT CALORIMETRY TEST
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
HCPCS 94690
|
| Hospital Charge Code |
46000011
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$192.96 |
| Rate for Payer: Aetna Commercial |
$154.77
|
| Rate for Payer: Anthem Medicaid |
$69.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$74.09
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$166.83
|
| Rate for Payer: First Health Commercial |
$190.95
|
| Rate for Payer: Humana Commercial |
$170.85
|
| Rate for Payer: Humana KY Medicaid |
$69.12
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$69.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.88
|
| Rate for Payer: Ohio Health Group HMO |
$150.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.69
|
| Rate for Payer: PHCS Commercial |
$192.96
|
| Rate for Payer: United Healthcare All Payer |
$176.88
|
|
|
INDIRECT CALORIMETRY TEST
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
HCPCS 94690
|
| Hospital Charge Code |
46000011
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$60.30 |
| Max. Negotiated Rate |
$192.96 |
| Rate for Payer: Aetna Commercial |
$154.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.78
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$166.83
|
| Rate for Payer: First Health Commercial |
$190.95
|
| Rate for Payer: Humana Commercial |
$170.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.88
|
| Rate for Payer: Ohio Health Group HMO |
$150.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$174.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$138.69
|
| Rate for Payer: PHCS Commercial |
$192.96
|
| Rate for Payer: United Healthcare All Payer |
$176.88
|
|
|
INDIUM 111 - IN PENTETREOTIDE
|
Facility
|
OP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
34000071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$486.27 |
| Max. Negotiated Rate |
$2,680.45 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem Medicaid |
$486.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,914.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,680.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,584.72
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Humana KY Medicaid |
$486.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,914.61
|
| Rate for Payer: Kentucky WC Medicaid |
$491.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,297.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$496.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,131.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,230.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$975.66
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM 111 - IN PENTETREOTIDE
|
Facility
|
IP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
34000071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$424.20 |
| Max. Negotiated Rate |
$1,357.44 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$424.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,131.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,230.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$975.66
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM 111 - IN PENTETREOTIDE
|
Professional
|
Both
|
$1,414.00
|
|
| Hospital Charge Code |
34000071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$494.90 |
| Max. Negotiated Rate |
$989.80 |
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Multiplan PHCS |
$848.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$989.80
|
| Rate for Payer: UHCCP Medicaid |
$494.90
|
|
|
INDIUM 111 - IN PENTETREOTID(T
|
Facility
|
IP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
340T0071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$424.20 |
| Max. Negotiated Rate |
$1,357.44 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$424.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,131.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,230.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$975.66
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM 111 - IN PENTETREOTID(T
|
Facility
|
OP
|
$1,414.00
|
|
|
Service Code
|
HCPCS A9572
|
| Hospital Charge Code |
340T0071
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$486.27 |
| Max. Negotiated Rate |
$2,680.45 |
| Rate for Payer: Aetna Commercial |
$1,088.78
|
| Rate for Payer: Anthem Medicaid |
$486.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,914.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,102.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,680.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,584.72
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cash Price |
$707.00
|
| Rate for Payer: Cigna Commercial |
$1,173.62
|
| Rate for Payer: First Health Commercial |
$1,343.30
|
| Rate for Payer: Humana Commercial |
$1,201.90
|
| Rate for Payer: Humana KY Medicaid |
$486.27
|
| Rate for Payer: Humana Medicare Advantage |
$1,914.61
|
| Rate for Payer: Kentucky WC Medicaid |
$491.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,159.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,043.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,297.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$496.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,244.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,060.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,131.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,230.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$975.66
|
| Rate for Payer: PHCS Commercial |
$1,357.44
|
| Rate for Payer: United Healthcare All Payer |
$1,244.32
|
|
|
INDIUM IN-111 AUTOLOGOUS WBCEL
|
Facility
|
OP
|
$6,993.00
|
|
|
Service Code
|
HCPCS A9570
|
| Hospital Charge Code |
34000070
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$1,031.39 |
| Max. Negotiated Rate |
$6,713.28 |
| Rate for Payer: Aetna Commercial |
$5,384.61
|
| Rate for Payer: Anthem Medicaid |
$2,404.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,031.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,454.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,443.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,392.38
|
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Cash Price |
$3,496.50
|
| Rate for Payer: Cigna Commercial |
$5,804.19
|
| Rate for Payer: First Health Commercial |
$6,643.35
|
| Rate for Payer: Humana Commercial |
$5,944.05
|
| Rate for Payer: Humana KY Medicaid |
$2,404.89
|
| Rate for Payer: Humana Medicare Advantage |
$1,031.39
|
| Rate for Payer: Kentucky WC Medicaid |
$2,429.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,734.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,160.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,453.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,153.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,244.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,594.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,083.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,825.17
|
| Rate for Payer: PHCS Commercial |
$6,713.28
|
| Rate for Payer: United Healthcare All Payer |
$6,153.84
|
|
