|
INSERTION OF SUBCU RESEV
|
Facility
|
IP
|
$1,700.00
|
|
|
Service Code
|
HCPCS 61215
|
| Hospital Charge Code |
76102284
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$510.00 |
| Max. Negotiated Rate |
$1,632.00 |
| Rate for Payer: Aetna Commercial |
$1,309.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,326.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$1,411.00
|
| Rate for Payer: First Health Commercial |
$1,615.00
|
| Rate for Payer: Humana Commercial |
$1,445.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,394.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,254.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$510.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,496.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,479.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,173.00
|
| Rate for Payer: PHCS Commercial |
$1,632.00
|
| Rate for Payer: United Healthcare All Payer |
$1,496.00
|
|
|
INSERTION OF SUBCU RESEV(P
|
Professional
|
Both
|
$1,700.00
|
|
|
Service Code
|
HCPCS 61215
|
| Hospital Charge Code |
761P2284
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$498.68 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Aetna Commercial |
$749.15
|
| Rate for Payer: Ambetter Exchange |
$498.68
|
| Rate for Payer: Anthem Medicaid |
$575.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$498.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$498.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$598.42
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cash Price |
$850.00
|
| Rate for Payer: Cigna Commercial |
$645.70
|
| Rate for Payer: Healthspan PPO |
$584.91
|
| Rate for Payer: Humana Medicaid |
$575.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$638.69
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$498.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$498.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$587.43
|
| Rate for Payer: Molina Healthcare Passport |
$575.91
|
| Rate for Payer: Multiplan PHCS |
$1,020.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$648.28
|
| Rate for Payer: UHCCP Medicaid |
$595.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$581.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$498.68
|
|
|
INSERTION OF TIPS
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 37182
|
| Hospital Charge Code |
76101523
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$1,415.40 |
| Rate for Payer: Aetna Commercial |
$1,415.40
|
| Rate for Payer: Ambetter Exchange |
$757.68
|
| Rate for Payer: Anthem Medicaid |
$691.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$757.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$757.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$909.22
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$1,278.55
|
| Rate for Payer: Healthspan PPO |
$1,131.74
|
| Rate for Payer: Humana Medicaid |
$691.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,101.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$757.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$757.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$705.53
|
| Rate for Payer: Molina Healthcare Passport |
$691.70
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$984.98
|
| Rate for Payer: UHCCP Medicaid |
$364.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$698.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$757.68
|
|
|
INSERTION OF TIPS
|
Facility
|
OP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 37182
|
| Hospital Charge Code |
76101523
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$998.40 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem Medicaid |
$357.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Humana KY Medicaid |
$357.66
|
| Rate for Payer: Kentucky WC Medicaid |
$361.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$364.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$832.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$717.60
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
INSERTION OF TIPS
|
Facility
|
IP
|
$1,040.00
|
|
|
Service Code
|
HCPCS 37182
|
| Hospital Charge Code |
76101523
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$998.40 |
| Rate for Payer: Aetna Commercial |
$800.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$811.20
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$863.20
|
| Rate for Payer: First Health Commercial |
$988.00
|
| Rate for Payer: Humana Commercial |
$884.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$852.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$767.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$312.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$915.20
|
| Rate for Payer: Ohio Health Group HMO |
$780.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$832.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$904.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$717.60
|
| Rate for Payer: PHCS Commercial |
$998.40
|
| Rate for Payer: United Healthcare All Payer |
$915.20
|
|
|
INSERTION OF TIPS(P
|
Professional
|
Both
|
$1,040.00
|
|
|
Service Code
|
HCPCS 37182
|
| Hospital Charge Code |
761P1523
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$364.00 |
| Max. Negotiated Rate |
$1,415.40 |
| Rate for Payer: Aetna Commercial |
$1,415.40
|
| Rate for Payer: Ambetter Exchange |
$757.68
|
| Rate for Payer: Anthem Medicaid |
$691.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$757.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$757.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$909.22
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna Commercial |
$1,278.55
|
| Rate for Payer: Healthspan PPO |
$1,131.74
|
| Rate for Payer: Humana Medicaid |
$691.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,101.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$757.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$757.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$705.53
|
| Rate for Payer: Molina Healthcare Passport |
$691.70
|
| Rate for Payer: Multiplan PHCS |
$624.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$984.98
|
| Rate for Payer: UHCCP Medicaid |
$364.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$698.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$757.68
|
|
|
INSERTION OF TUNNELED CENTRALL
|
Facility
|
OP
|
$6,518.00
|
|
|
Service Code
|
HCPCS 36561
|
| Hospital Charge Code |
761T1476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,241.54 |
| Max. Negotiated Rate |
$6,257.28 |
| Rate for Payer: Aetna Commercial |
$5,018.86
|
| Rate for Payer: Anthem Medicaid |
$2,241.54
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,084.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Cash Price |
$3,259.00
|
| Rate for Payer: Cash Price |
$3,259.00
|
| Rate for Payer: Cigna Commercial |
$5,409.94
|
| Rate for Payer: First Health Commercial |
$6,192.10
|
| Rate for Payer: Humana Commercial |
$5,540.30
|
| Rate for Payer: Humana KY Medicaid |
$2,241.54
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,264.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,344.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,810.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,286.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,735.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,888.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,214.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,670.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,497.42
|
| Rate for Payer: PHCS Commercial |
$6,257.28
|
| Rate for Payer: United Healthcare All Payer |
$5,735.84
|
|
|
INSERTION OF TUNNELED CENTRALL
|
Professional
|
Both
|
$1,560.00
|
|
|
Service Code
|
HCPCS 36561
|
| Hospital Charge Code |
761P1476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.07 |
| Max. Negotiated Rate |
$1,330.97 |
| Rate for Payer: Aetna Commercial |
$538.47
|
| Rate for Payer: Ambetter Exchange |
$310.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$240.07
|
| Rate for Payer: Anthem Medicaid |
$269.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$310.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$310.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$372.31
|
| Rate for Payer: Cash Price |
$780.00
|
| Rate for Payer: Cash Price |
$780.00
|
| Rate for Payer: Cigna Commercial |
$508.87
|
| Rate for Payer: Healthspan PPO |
$1,330.97
|
| Rate for Payer: Humana Medicaid |
$269.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$456.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$310.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$310.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$275.31
|
| Rate for Payer: Molina Healthcare Passport |
$269.91
|
| Rate for Payer: Multiplan PHCS |
$936.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$403.34
|
| Rate for Payer: UHCCP Medicaid |
$252.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$272.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$310.26
|
|
|
INSERTION OF TUNNELED CENTRALL
|
Facility
|
IP
|
$8,078.00
|
|
|
Service Code
|
HCPCS 36561
|
| Hospital Charge Code |
76101476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,423.40 |
| Max. Negotiated Rate |
$7,754.88 |
| Rate for Payer: Aetna Commercial |
$6,220.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,300.84
|
| Rate for Payer: Cash Price |
$4,039.00
|
| Rate for Payer: Cigna Commercial |
$6,704.74
|
| Rate for Payer: First Health Commercial |
$7,674.10
|
| Rate for Payer: Humana Commercial |
$6,866.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,623.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,961.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,423.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,108.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,058.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,462.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,027.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,573.82
|
| Rate for Payer: PHCS Commercial |
$7,754.88
|
| Rate for Payer: United Healthcare All Payer |
$7,108.64
|
|
|
INSERTION OF TUNNELED CENTRALL
|
Professional
|
Both
|
$8,078.00
|
|
|
Service Code
|
HCPCS 36561
|
| Hospital Charge Code |
76101476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.07 |
| Max. Negotiated Rate |
$4,846.80 |
| Rate for Payer: Aetna Commercial |
$538.47
|
| Rate for Payer: Ambetter Exchange |
$310.26
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$240.07
|
| Rate for Payer: Anthem Medicaid |
$269.91
|
| Rate for Payer: Buckeye Individual/Medicaid |
$310.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$310.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$372.31
|
| Rate for Payer: Cash Price |
$4,039.00
|
| Rate for Payer: Cash Price |
$4,039.00
|
| Rate for Payer: Cigna Commercial |
$508.87
|
| Rate for Payer: Healthspan PPO |
$1,330.97
|
| Rate for Payer: Humana Medicaid |
$269.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$456.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$310.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$310.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$275.31
|
| Rate for Payer: Molina Healthcare Passport |
$269.91
|
| Rate for Payer: Multiplan PHCS |
$4,846.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$403.34
|
| Rate for Payer: UHCCP Medicaid |
$252.07
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$272.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$310.26
|
|
|
INSERTION OF TUNNELED CENTRALL
|
Facility
|
OP
|
$8,078.00
|
|
|
Service Code
|
HCPCS 36561
|
| Hospital Charge Code |
76101476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,778.02 |
| Max. Negotiated Rate |
$7,754.88 |
| Rate for Payer: Aetna Commercial |
$6,220.06
|
| Rate for Payer: Anthem Medicaid |
$2,778.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,300.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Cash Price |
$4,039.00
|
| Rate for Payer: Cash Price |
$4,039.00
|
| Rate for Payer: Cigna Commercial |
$6,704.74
|
| Rate for Payer: First Health Commercial |
$7,674.10
|
| Rate for Payer: Humana Commercial |
$6,866.30
|
| Rate for Payer: Humana KY Medicaid |
$2,778.02
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,806.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,623.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,961.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,833.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,108.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,058.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,462.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,027.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,573.82
|
| Rate for Payer: PHCS Commercial |
$7,754.88
|
| Rate for Payer: United Healthcare All Payer |
$7,108.64
|
|
|
INSERTION OF TUNNELED CENTRALL
|
Facility
|
IP
|
$6,518.00
|
|
|
Service Code
|
HCPCS 36561
|
| Hospital Charge Code |
761T1476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,955.40 |
| Max. Negotiated Rate |
$6,257.28 |
| Rate for Payer: Aetna Commercial |
$5,018.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,084.04
|
| Rate for Payer: Cash Price |
$3,259.00
|
| Rate for Payer: Cigna Commercial |
$5,409.94
|
| Rate for Payer: First Health Commercial |
$6,192.10
|
| Rate for Payer: Humana Commercial |
$5,540.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,344.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,810.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,955.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,735.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,888.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,214.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,670.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,497.42
|
| Rate for Payer: PHCS Commercial |
$6,257.28
|
| Rate for Payer: United Healthcare All Payer |
$5,735.84
|
|
|
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER
|
Facility
|
OP
|
$4,071.52
|
|
|
Service Code
|
CPT 36561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,908.23 |
| Max. Negotiated Rate |
$4,071.52 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
|
|
INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER
|
Facility
|
OP
|
$4,071.52
|
|
|
Service Code
|
CPT 36558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,908.23 |
| Max. Negotiated Rate |
$4,071.52 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,908.23
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,071.52
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,926.11
|
| Rate for Payer: Humana Medicare Advantage |
$2,908.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,489.88
|
|
|
INSERTION OR REPLACEMENT OF BREAST IMPLANT ON SEPARATE DAY FROM MASTECTOMY
|
Facility
|
OP
|
$12,378.25
|
|
|
Service Code
|
CPT 19342
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$8,841.61 |
| Max. Negotiated Rate |
$12,378.25 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,841.61
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,378.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,936.17
|
| Rate for Payer: Humana Medicare Advantage |
$8,841.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,609.93
|
|
|
INSERTION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH SUBSTERNAL ELECTRODE(S), INCLUDING ALL IMAGING GUIDANCE AND ELECTROPHYSIOLOGICAL EVALUATION (INCLUDES DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS), WHEN PERFORMED
|
Facility
|
OP
|
$41,473.96
|
|
|
Service Code
|
CPT 0571T
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$29,624.26 |
| Max. Negotiated Rate |
$41,473.96 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$29,624.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$41,473.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$39,992.75
|
| Rate for Payer: Humana Medicare Advantage |
$29,624.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35,549.11
|
|
|
INSERTION OR REPLACEMENT OF PERIPHERAL, SACRAL, OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
|
Facility
|
OP
|
$27,739.87
|
|
|
Service Code
|
CPT 64590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$19,814.19 |
| Max. Negotiated Rate |
$27,739.87 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$19,814.19
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$27,739.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$26,749.16
|
| Rate for Payer: Humana Medicare Advantage |
$19,814.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,777.03
|
|
|
INSERTION OR REPLACEMENT OF PERMANENT IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER
|
Facility
|
OP
|
$41,473.96
|
|
|
Service Code
|
CPT 33249
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$29,624.26 |
| Max. Negotiated Rate |
$41,473.96 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$29,624.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$41,473.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$39,992.75
|
| Rate for Payer: Humana Medicare Advantage |
$29,624.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35,549.11
|
|
|
INSERTION OR REPLACEMENT OF PERMANENT SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH SUBCUTANEOUS ELECTRODE, INCLUDING DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS, WHEN PERFORMED
|
Facility
|
OP
|
$41,473.96
|
|
|
Service Code
|
CPT 33270
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$29,624.26 |
| Max. Negotiated Rate |
$41,473.96 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$29,624.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$41,473.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$39,992.75
|
| Rate for Payer: Humana Medicare Advantage |
$29,624.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35,549.11
|
|
|
INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, REQUIRING POCKET CREATION AND CONNECTION BETWEEN ELECTRODE ARRAY AND PULSE GENERATOR OR RECEIVER
|
Facility
|
OP
|
$39,419.79
|
|
|
Service Code
|
CPT 63685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$28,156.99 |
| Max. Negotiated Rate |
$39,419.79 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28,156.99
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39,419.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$38,011.94
|
| Rate for Payer: Humana Medicare Advantage |
$28,156.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33,788.39
|
|
|
INSERTION VAG TANDEM/OVOID HDR
|
Facility
|
OP
|
$3,117.00
|
|
|
Service Code
|
HCPCS 57155
|
| Hospital Charge Code |
76102175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,071.94 |
| Max. Negotiated Rate |
$6,385.65 |
| Rate for Payer: Aetna Commercial |
$2,400.09
|
| Rate for Payer: Anthem Medicaid |
$1,071.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,561.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,431.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,385.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,157.59
|
| Rate for Payer: Cash Price |
$1,558.50
|
| Rate for Payer: Cash Price |
$1,558.50
|
| Rate for Payer: Cigna Commercial |
$2,587.11
|
| Rate for Payer: First Health Commercial |
$2,961.15
|
| Rate for Payer: Humana Commercial |
$2,649.45
|
| Rate for Payer: Humana KY Medicaid |
$1,071.94
|
| Rate for Payer: Humana Medicare Advantage |
$4,561.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,082.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,555.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,300.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,473.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,093.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,742.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,337.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,493.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,150.73
|
| Rate for Payer: PHCS Commercial |
$2,992.32
|
| Rate for Payer: United Healthcare All Payer |
$2,742.96
|
|
|
INSERTION VAG TANDEM/OVOID HDR
|
Facility
|
IP
|
$3,117.00
|
|
|
Service Code
|
HCPCS 57155
|
| Hospital Charge Code |
76102175
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$935.10 |
| Max. Negotiated Rate |
$2,992.32 |
| Rate for Payer: Aetna Commercial |
$2,400.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,431.26
|
| Rate for Payer: Cash Price |
$1,558.50
|
| Rate for Payer: Cigna Commercial |
$2,587.11
|
| Rate for Payer: First Health Commercial |
$2,961.15
|
| Rate for Payer: Humana Commercial |
$2,649.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,555.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,300.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$935.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,742.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,337.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,493.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,711.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,150.73
|
| Rate for Payer: PHCS Commercial |
$2,992.32
|
| Rate for Payer: United Healthcare All Payer |
$2,742.96
|
|
|
INSERT JOURNEY REV STD 3-4 L 9
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JOURNEY REV STD 3-4 L 9
|
Facility
|
IP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JOURNEY REV STD 5-6 R 9
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
