|
INFLUX SPARC - 10CC
|
Facility
|
OP
|
$23,187.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,956.25 |
| Max. Negotiated Rate |
$22,260.00 |
| Rate for Payer: Aetna Commercial |
$17,854.38
|
| Rate for Payer: Anthem Medicaid |
$7,974.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,086.25
|
| Rate for Payer: Cash Price |
$11,593.75
|
| Rate for Payer: Cigna Commercial |
$19,245.62
|
| Rate for Payer: First Health Commercial |
$22,028.12
|
| Rate for Payer: Humana Commercial |
$19,709.38
|
| Rate for Payer: Humana KY Medicaid |
$7,974.18
|
| Rate for Payer: Kentucky WC Medicaid |
$8,055.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,013.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,112.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,956.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,134.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,405.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,390.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,173.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,999.38
|
| Rate for Payer: PHCS Commercial |
$22,260.00
|
| Rate for Payer: United Healthcare All Payer |
$20,405.00
|
|
|
INFLUX SPARC - 10CC
|
Facility
|
IP
|
$23,187.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,956.25 |
| Max. Negotiated Rate |
$22,260.00 |
| Rate for Payer: Aetna Commercial |
$17,854.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,086.25
|
| Rate for Payer: Cash Price |
$11,593.75
|
| Rate for Payer: Cigna Commercial |
$19,245.62
|
| Rate for Payer: First Health Commercial |
$22,028.12
|
| Rate for Payer: Humana Commercial |
$19,709.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,013.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,112.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,956.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,405.00
|
| Rate for Payer: Ohio Health Group HMO |
$17,390.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,173.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,999.38
|
| Rate for Payer: PHCS Commercial |
$22,260.00
|
| Rate for Payer: United Healthcare All Payer |
$20,405.00
|
|
|
INFLUX SPARC - 1CC
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
INFLUX SPARC - 1CC
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1762
|
| Hospital Charge Code |
27000051
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
INFUSE BONE GRAFT LARGE
|
Facility
|
IP
|
$24,125.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,237.50 |
| Max. Negotiated Rate |
$23,160.00 |
| Rate for Payer: Aetna Commercial |
$18,576.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,817.50
|
| Rate for Payer: Cash Price |
$12,062.50
|
| Rate for Payer: Cigna Commercial |
$20,023.75
|
| Rate for Payer: First Health Commercial |
$22,918.75
|
| Rate for Payer: Humana Commercial |
$20,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,782.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,804.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,230.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,988.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,646.25
|
| Rate for Payer: PHCS Commercial |
$23,160.00
|
| Rate for Payer: United Healthcare All Payer |
$21,230.00
|
|
|
INFUSE BONE GRAFT LARGE
|
Facility
|
OP
|
$24,125.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,237.50 |
| Max. Negotiated Rate |
$23,160.00 |
| Rate for Payer: Aetna Commercial |
$18,576.25
|
| Rate for Payer: Anthem Medicaid |
$8,296.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,817.50
|
| Rate for Payer: Cash Price |
$12,062.50
|
| Rate for Payer: Cigna Commercial |
$20,023.75
|
| Rate for Payer: First Health Commercial |
$22,918.75
|
| Rate for Payer: Humana Commercial |
$20,506.25
|
| Rate for Payer: Humana KY Medicaid |
$8,296.59
|
| Rate for Payer: Kentucky WC Medicaid |
$8,381.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,782.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,804.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,463.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,230.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,988.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,646.25
|
| Rate for Payer: PHCS Commercial |
$23,160.00
|
| Rate for Payer: United Healthcare All Payer |
$21,230.00
|
|
|
INFUSE BONE GRAFT LARGE II
|
Facility
|
OP
|
$24,125.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,237.50 |
| Max. Negotiated Rate |
$23,160.00 |
| Rate for Payer: Aetna Commercial |
$18,576.25
|
| Rate for Payer: Anthem Medicaid |
$8,296.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,817.50
|
| Rate for Payer: Cash Price |
$12,062.50
|
| Rate for Payer: Cigna Commercial |
$20,023.75
|
| Rate for Payer: First Health Commercial |
$22,918.75
|
| Rate for Payer: Humana Commercial |
$20,506.25
|
| Rate for Payer: Humana KY Medicaid |
$8,296.59
|
| Rate for Payer: Kentucky WC Medicaid |
$8,381.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,782.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,804.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,463.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,230.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,988.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,646.25
|
| Rate for Payer: PHCS Commercial |
$23,160.00
|
| Rate for Payer: United Healthcare All Payer |
$21,230.00
|
|
|
INFUSE BONE GRAFT LARGE II
|
Facility
|
IP
|
$24,125.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,237.50 |
| Max. Negotiated Rate |
$23,160.00 |
| Rate for Payer: Aetna Commercial |
$18,576.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,817.50
|
| Rate for Payer: Cash Price |
$12,062.50
|
| Rate for Payer: Cigna Commercial |
$20,023.75
|
| Rate for Payer: First Health Commercial |
$22,918.75
|
| Rate for Payer: Humana Commercial |
$20,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,782.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,804.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,230.00
|
| Rate for Payer: Ohio Health Group HMO |
$18,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,988.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,646.25
|
| Rate for Payer: PHCS Commercial |
$23,160.00
|
| Rate for Payer: United Healthcare All Payer |
$21,230.00
|
|
|
INFUSE BONE GRAFT MEDIUM
|
Facility
|
IP
|
$22,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,675.00 |
| Max. Negotiated Rate |
$21,360.00 |
| Rate for Payer: Aetna Commercial |
$17,132.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,355.00
|
| Rate for Payer: Cash Price |
$11,125.00
|
| Rate for Payer: Cigna Commercial |
$18,467.50
|
| Rate for Payer: First Health Commercial |
$21,137.50
|
| Rate for Payer: Humana Commercial |
$18,912.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,245.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,420.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,675.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,580.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,357.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,352.50
|
| Rate for Payer: PHCS Commercial |
$21,360.00
|
| Rate for Payer: United Healthcare All Payer |
$19,580.00
|
|
|
INFUSE BONE GRAFT MEDIUM
|
Facility
|
OP
|
$22,250.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,675.00 |
| Max. Negotiated Rate |
$21,360.00 |
| Rate for Payer: Aetna Commercial |
$17,132.50
|
| Rate for Payer: Anthem Medicaid |
$7,651.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,355.00
|
| Rate for Payer: Cash Price |
$11,125.00
|
| Rate for Payer: Cigna Commercial |
$18,467.50
|
| Rate for Payer: First Health Commercial |
$21,137.50
|
| Rate for Payer: Humana Commercial |
$18,912.50
|
| Rate for Payer: Humana KY Medicaid |
$7,651.77
|
| Rate for Payer: Kentucky WC Medicaid |
$7,729.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,245.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,420.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,675.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,805.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,580.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,687.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,357.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,352.50
|
| Rate for Payer: PHCS Commercial |
$21,360.00
|
| Rate for Payer: United Healthcare All Payer |
$19,580.00
|
|
|
INFUSE BONE GRAFT SMALL
|
Facility
|
IP
|
$17,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,316.00 |
| Max. Negotiated Rate |
$17,011.20 |
| Rate for Payer: Aetna Commercial |
$13,644.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,821.60
|
| Rate for Payer: Cash Price |
$8,860.00
|
| Rate for Payer: Cigna Commercial |
$14,707.60
|
| Rate for Payer: First Health Commercial |
$16,834.00
|
| Rate for Payer: Humana Commercial |
$15,062.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,530.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,077.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,316.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,593.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,290.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,416.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,226.80
|
| Rate for Payer: PHCS Commercial |
$17,011.20
|
| Rate for Payer: United Healthcare All Payer |
$15,593.60
|
|
|
INFUSE BONE GRAFT SMALL
|
Facility
|
OP
|
$17,720.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,316.00 |
| Max. Negotiated Rate |
$17,011.20 |
| Rate for Payer: Aetna Commercial |
$13,644.40
|
| Rate for Payer: Anthem Medicaid |
$6,093.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,821.60
|
| Rate for Payer: Cash Price |
$8,860.00
|
| Rate for Payer: Cigna Commercial |
$14,707.60
|
| Rate for Payer: First Health Commercial |
$16,834.00
|
| Rate for Payer: Humana Commercial |
$15,062.00
|
| Rate for Payer: Humana KY Medicaid |
$6,093.91
|
| Rate for Payer: Kentucky WC Medicaid |
$6,155.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,530.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,077.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,316.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,216.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,593.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,290.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,416.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,226.80
|
| Rate for Payer: PHCS Commercial |
$17,011.20
|
| Rate for Payer: United Healthcare All Payer |
$15,593.60
|
|
|
INFUSE RADIOACTIVE MATERIAL
|
Professional
|
Both
|
$1,435.00
|
|
|
Service Code
|
HCPCS 77750
|
| Hospital Charge Code |
33300029
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$232.97 |
| Max. Negotiated Rate |
$861.00 |
| Rate for Payer: Aetna Commercial |
$529.55
|
| Rate for Payer: Ambetter Exchange |
$368.40
|
| Rate for Payer: Anthem Medicaid |
$232.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$368.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$368.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$442.08
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cigna Commercial |
$463.90
|
| Rate for Payer: Healthspan PPO |
$446.58
|
| Rate for Payer: Humana Medicaid |
$232.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$319.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$368.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$368.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$237.63
|
| Rate for Payer: Molina Healthcare Passport |
$232.97
|
| Rate for Payer: Multiplan PHCS |
$861.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$478.92
|
| Rate for Payer: UHCCP Medicaid |
$502.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$235.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$368.40
|
|
|
INFUSE RADIOACTIVE MATERIAL
|
Facility
|
IP
|
$1,435.00
|
|
|
Service Code
|
HCPCS 77750
|
| Hospital Charge Code |
33300029
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$430.50 |
| Max. Negotiated Rate |
$1,377.60 |
| Rate for Payer: Aetna Commercial |
$1,104.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,119.30
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cigna Commercial |
$1,191.05
|
| Rate for Payer: First Health Commercial |
$1,363.25
|
| Rate for Payer: Humana Commercial |
$1,219.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,176.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,059.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$430.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,262.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,076.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,148.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$990.15
|
| Rate for Payer: PHCS Commercial |
$1,377.60
|
| Rate for Payer: United Healthcare All Payer |
$1,262.80
|
|
|
INFUSE RADIOACTIVE MATERIAL
|
Facility
|
OP
|
$1,435.00
|
|
|
Service Code
|
HCPCS 77750
|
| Hospital Charge Code |
33300029
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$242.99 |
| Max. Negotiated Rate |
$1,377.60 |
| Rate for Payer: Aetna Commercial |
$1,104.95
|
| Rate for Payer: Anthem Medicaid |
$493.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$242.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,119.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$340.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$328.04
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cash Price |
$717.50
|
| Rate for Payer: Cigna Commercial |
$1,191.05
|
| Rate for Payer: First Health Commercial |
$1,363.25
|
| Rate for Payer: Humana Commercial |
$1,219.75
|
| Rate for Payer: Humana KY Medicaid |
$493.50
|
| Rate for Payer: Humana Medicare Advantage |
$242.99
|
| Rate for Payer: Kentucky WC Medicaid |
$498.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,176.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,059.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$503.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,262.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,076.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,148.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,248.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$990.15
|
| Rate for Payer: PHCS Commercial |
$1,377.60
|
| Rate for Payer: United Healthcare All Payer |
$1,262.80
|
|
|
INFUSE RADIOACTIVE MATERIAL(P
|
Professional
|
Both
|
$850.00
|
|
|
Service Code
|
HCPCS 77750
|
| Hospital Charge Code |
333P0029
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$232.97 |
| Max. Negotiated Rate |
$529.55 |
| Rate for Payer: Aetna Commercial |
$529.55
|
| Rate for Payer: Ambetter Exchange |
$368.40
|
| Rate for Payer: Anthem Medicaid |
$232.97
|
| Rate for Payer: Buckeye Individual/Medicaid |
$368.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$368.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$442.08
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$463.90
|
| Rate for Payer: Healthspan PPO |
$446.58
|
| Rate for Payer: Humana Medicaid |
$232.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$319.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$368.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$368.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$237.63
|
| Rate for Payer: Molina Healthcare Passport |
$232.97
|
| Rate for Payer: Multiplan PHCS |
$510.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$478.92
|
| Rate for Payer: UHCCP Medicaid |
$297.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$235.30
|
| Rate for Payer: Wellcare Medicare Advantage |
$368.40
|
|
|
INFUSE RADIOACTIVE MATERIAL(T
|
Facility
|
OP
|
$585.00
|
|
|
Service Code
|
HCPCS 77750
|
| Hospital Charge Code |
333T0029
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$201.18 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: Aetna Commercial |
$450.45
|
| Rate for Payer: Anthem Medicaid |
$201.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$242.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$456.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$340.19
|
| Rate for Payer: CareSource Just4Me Medicare |
$328.04
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$485.55
|
| Rate for Payer: First Health Commercial |
$555.75
|
| Rate for Payer: Humana Commercial |
$497.25
|
| Rate for Payer: Humana KY Medicaid |
$201.18
|
| Rate for Payer: Humana Medicare Advantage |
$242.99
|
| Rate for Payer: Kentucky WC Medicaid |
$203.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$479.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$431.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$291.59
|
| Rate for Payer: Molina Healthcare Medicaid |
$205.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$514.80
|
| Rate for Payer: Ohio Health Group HMO |
$438.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.65
|
| Rate for Payer: PHCS Commercial |
$561.60
|
| Rate for Payer: United Healthcare All Payer |
$514.80
|
|
|
INFUSE RADIOACTIVE MATERIAL(T
|
Facility
|
IP
|
$585.00
|
|
|
Service Code
|
HCPCS 77750
|
| Hospital Charge Code |
333T0029
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$175.50 |
| Max. Negotiated Rate |
$561.60 |
| Rate for Payer: Aetna Commercial |
$450.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$456.30
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: Cigna Commercial |
$485.55
|
| Rate for Payer: First Health Commercial |
$555.75
|
| Rate for Payer: Humana Commercial |
$497.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$479.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$431.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$175.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$514.80
|
| Rate for Payer: Ohio Health Group HMO |
$438.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$508.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.65
|
| Rate for Payer: PHCS Commercial |
$561.60
|
| Rate for Payer: United Healthcare All Payer |
$514.80
|
|
|
INFUSION PORT 6F
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
INFUSION PORT 6F
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1788
|
| Hospital Charge Code |
27000108
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
INFUVITE PED 5mL SDV
|
Facility
|
OP
|
$131.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004375
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$100.91
|
| Rate for Payer: Anthem Medicaid |
$45.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.22
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Cigna Commercial |
$108.77
|
| Rate for Payer: First Health Commercial |
$124.50
|
| Rate for Payer: Humana Commercial |
$111.39
|
| Rate for Payer: Humana KY Medicaid |
$45.07
|
| Rate for Payer: Kentucky WC Medicaid |
$45.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$45.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.32
|
| Rate for Payer: Ohio Health Group HMO |
$98.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.42
|
| Rate for Payer: PHCS Commercial |
$125.81
|
| Rate for Payer: United Healthcare All Payer |
$115.32
|
|
|
INFUVITE PED 5mL SDV
|
Facility
|
IP
|
$131.05
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004375
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$125.81 |
| Rate for Payer: Aetna Commercial |
$100.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$102.22
|
| Rate for Payer: Cash Price |
$65.53
|
| Rate for Payer: Cigna Commercial |
$108.77
|
| Rate for Payer: First Health Commercial |
$124.50
|
| Rate for Payer: Humana Commercial |
$111.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$107.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$96.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$115.32
|
| Rate for Payer: Ohio Health Group HMO |
$98.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$114.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$90.42
|
| Rate for Payer: PHCS Commercial |
$125.81
|
| Rate for Payer: United Healthcare All Payer |
$115.32
|
|
|
INGEST CHALLENGE INI 120 MIN
|
Facility
|
OP
|
$751.00
|
|
|
Service Code
|
HCPCS 95076
|
| Hospital Charge Code |
92200019
|
|
Hospital Revenue Code
|
924
|
| Min. Negotiated Rate |
$258.27 |
| Max. Negotiated Rate |
$720.96 |
| Rate for Payer: Aetna Commercial |
$578.27
|
| Rate for Payer: Anthem Medicaid |
$258.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$490.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.78
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$686.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$661.85
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$623.33
|
| Rate for Payer: First Health Commercial |
$713.45
|
| Rate for Payer: Humana Commercial |
$638.35
|
| Rate for Payer: Humana KY Medicaid |
$258.27
|
| Rate for Payer: Humana Medicare Advantage |
$490.26
|
| Rate for Payer: Kentucky WC Medicaid |
$260.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$554.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.88
|
| Rate for Payer: Ohio Health Group HMO |
$563.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$653.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$518.19
|
| Rate for Payer: PHCS Commercial |
$720.96
|
| Rate for Payer: United Healthcare All Payer |
$660.88
|
|
|
INGEST CHALLENGE INI 120 MIN
|
Facility
|
IP
|
$751.00
|
|
|
Service Code
|
HCPCS 95076
|
| Hospital Charge Code |
92200019
|
|
Hospital Revenue Code
|
924
|
| Min. Negotiated Rate |
$225.30 |
| Max. Negotiated Rate |
$720.96 |
| Rate for Payer: Aetna Commercial |
$578.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.78
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$623.33
|
| Rate for Payer: First Health Commercial |
$713.45
|
| Rate for Payer: Humana Commercial |
$638.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$554.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.88
|
| Rate for Payer: Ohio Health Group HMO |
$563.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$653.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$518.19
|
| Rate for Payer: PHCS Commercial |
$720.96
|
| Rate for Payer: United Healthcare All Payer |
$660.88
|
|
|
INGEST CHALLENGE INI 120 MIN
|
Professional
|
Both
|
$751.00
|
|
|
Service Code
|
HCPCS 95076
|
| Hospital Charge Code |
92200019
|
|
Hospital Revenue Code
|
924
|
| Min. Negotiated Rate |
$56.65 |
| Max. Negotiated Rate |
$450.60 |
| Rate for Payer: Ambetter Exchange |
$69.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$56.65
|
| Rate for Payer: Anthem Medicaid |
$92.66
|
| Rate for Payer: Buckeye Individual/Medicaid |
$69.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$69.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$82.86
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cash Price |
$375.50
|
| Rate for Payer: Cigna Commercial |
$195.09
|
| Rate for Payer: Healthspan PPO |
$150.63
|
| Rate for Payer: Humana Medicaid |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$85.33
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$69.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$94.51
|
| Rate for Payer: Molina Healthcare Passport |
$92.66
|
| Rate for Payer: Multiplan PHCS |
$450.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$89.77
|
| Rate for Payer: UHCCP Medicaid |
$59.48
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$93.59
|
| Rate for Payer: Wellcare Medicare Advantage |
$69.05
|
|
