|
INTERSPACE SHOULDER KIT 46MM
|
Facility
|
OP
|
$17,023.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,213.02 |
| Max. Negotiated Rate |
$16,342.27 |
| Rate for Payer: Aetna Commercial |
$13,107.86
|
| Rate for Payer: Anthem Medicaid |
$5,854.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,278.10
|
| Rate for Payer: Cash Price |
$8,511.60
|
| Rate for Payer: Cigna Commercial |
$14,129.26
|
| Rate for Payer: First Health Commercial |
$16,172.04
|
| Rate for Payer: Humana Commercial |
$14,469.72
|
| Rate for Payer: Humana KY Medicaid |
$5,854.28
|
| Rate for Payer: Kentucky WC Medicaid |
$5,913.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,959.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,563.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,106.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,971.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,980.42
|
| Rate for Payer: Ohio Health Group HMO |
$12,767.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,404.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,213.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,277.19
|
| Rate for Payer: PHCS Commercial |
$16,342.27
|
| Rate for Payer: United Healthcare All Payer |
$14,980.42
|
|
|
INTERSPACE SHOULDER KIT 46MM
|
Facility
|
IP
|
$17,023.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,213.02 |
| Max. Negotiated Rate |
$16,342.27 |
| Rate for Payer: Aetna Commercial |
$13,107.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,278.10
|
| Rate for Payer: Cash Price |
$8,511.60
|
| Rate for Payer: Cigna Commercial |
$14,129.26
|
| Rate for Payer: First Health Commercial |
$16,172.04
|
| Rate for Payer: Humana Commercial |
$14,469.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,959.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,563.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,106.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,980.42
|
| Rate for Payer: Ohio Health Group HMO |
$12,767.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,404.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,213.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,277.19
|
| Rate for Payer: PHCS Commercial |
$16,342.27
|
| Rate for Payer: United Healthcare All Payer |
$14,980.42
|
|
|
INTERSTIM ANTENNA 37092
|
Facility
|
IP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
INTERSTIM ANTENNA 37092
|
Facility
|
OP
|
$1,530.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.90 |
| Max. Negotiated Rate |
$1,468.80 |
| Rate for Payer: Aetna Commercial |
$1,178.10
|
| Rate for Payer: Anthem Medicaid |
$526.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,193.40
|
| Rate for Payer: Cash Price |
$765.00
|
| Rate for Payer: Cigna Commercial |
$1,269.90
|
| Rate for Payer: First Health Commercial |
$1,453.50
|
| Rate for Payer: Humana Commercial |
$1,300.50
|
| Rate for Payer: Humana KY Medicaid |
$526.17
|
| Rate for Payer: Kentucky WC Medicaid |
$531.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,254.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,129.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$459.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$536.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,346.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,147.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$306.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$474.30
|
| Rate for Payer: PHCS Commercial |
$1,468.80
|
| Rate for Payer: United Healthcare All Payer |
$1,346.40
|
|
|
INTERSTIM LEAD 4.32MM 28CM
|
Facility
|
IP
|
$19,650.94
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.62 |
| Max. Negotiated Rate |
$18,864.90 |
| Rate for Payer: Aetna Commercial |
$15,131.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,327.73
|
| Rate for Payer: Cash Price |
$9,825.47
|
| Rate for Payer: Cigna Commercial |
$16,310.28
|
| Rate for Payer: First Health Commercial |
$18,668.39
|
| Rate for Payer: Humana Commercial |
$16,703.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,113.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,502.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,895.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,292.83
|
| Rate for Payer: Ohio Health Group HMO |
$14,738.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,930.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,554.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,091.79
|
| Rate for Payer: PHCS Commercial |
$18,864.90
|
| Rate for Payer: United Healthcare All Payer |
$17,292.83
|
|
|
INTERSTIM LEAD 4.32MM 28CM
|
Facility
|
OP
|
$19,650.94
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,554.62 |
| Max. Negotiated Rate |
$18,864.90 |
| Rate for Payer: Aetna Commercial |
$15,131.22
|
| Rate for Payer: Anthem Medicaid |
$6,757.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,327.73
|
| Rate for Payer: Cash Price |
$9,825.47
|
| Rate for Payer: Cigna Commercial |
$16,310.28
|
| Rate for Payer: First Health Commercial |
$18,668.39
|
| Rate for Payer: Humana Commercial |
$16,703.30
|
| Rate for Payer: Humana KY Medicaid |
$6,757.96
|
| Rate for Payer: Kentucky WC Medicaid |
$6,826.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,113.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,502.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,895.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,893.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,292.83
|
| Rate for Payer: Ohio Health Group HMO |
$14,738.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,930.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,554.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,091.79
|
| Rate for Payer: PHCS Commercial |
$18,864.90
|
| Rate for Payer: United Healthcare All Payer |
$17,292.83
|
|
|
INTERSTIM LEAD INTRODUCER KIT
|
Facility
|
IP
|
$3,180.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$413.40 |
| Max. Negotiated Rate |
$3,052.80 |
| Rate for Payer: Aetna Commercial |
$2,448.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,480.40
|
| Rate for Payer: Cash Price |
$1,590.00
|
| Rate for Payer: Cigna Commercial |
$2,639.40
|
| Rate for Payer: First Health Commercial |
$3,021.00
|
| Rate for Payer: Humana Commercial |
$2,703.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,607.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,346.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$954.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,798.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,385.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$985.80
|
| Rate for Payer: PHCS Commercial |
$3,052.80
|
| Rate for Payer: United Healthcare All Payer |
$2,798.40
|
|
|
INTERSTIM LEAD INTRODUCER KIT
|
Facility
|
OP
|
$3,180.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$413.40 |
| Max. Negotiated Rate |
$3,052.80 |
| Rate for Payer: Aetna Commercial |
$2,448.60
|
| Rate for Payer: Anthem Medicaid |
$1,093.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,480.40
|
| Rate for Payer: Cash Price |
$1,590.00
|
| Rate for Payer: Cigna Commercial |
$2,639.40
|
| Rate for Payer: First Health Commercial |
$3,021.00
|
| Rate for Payer: Humana Commercial |
$2,703.00
|
| Rate for Payer: Humana KY Medicaid |
$1,093.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,104.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,607.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,346.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$954.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,115.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,798.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,385.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$985.80
|
| Rate for Payer: PHCS Commercial |
$3,052.80
|
| Rate for Payer: United Healthcare All Payer |
$2,798.40
|
|
|
INTERSTIM LEAD KIT 3093-28
|
Facility
|
OP
|
$16,026.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,083.38 |
| Max. Negotiated Rate |
$15,384.96 |
| Rate for Payer: Aetna Commercial |
$12,340.02
|
| Rate for Payer: Anthem Medicaid |
$5,511.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,500.28
|
| Rate for Payer: Cash Price |
$8,013.00
|
| Rate for Payer: Cigna Commercial |
$13,301.58
|
| Rate for Payer: First Health Commercial |
$15,224.70
|
| Rate for Payer: Humana Commercial |
$13,622.10
|
| Rate for Payer: Humana KY Medicaid |
$5,511.34
|
| Rate for Payer: Kentucky WC Medicaid |
$5,567.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,141.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,827.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,807.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,621.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,102.88
|
| Rate for Payer: Ohio Health Group HMO |
$12,019.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,205.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,083.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,968.06
|
| Rate for Payer: PHCS Commercial |
$15,384.96
|
| Rate for Payer: United Healthcare All Payer |
$14,102.88
|
|
|
INTERSTIM LEAD KIT 3093-28
|
Facility
|
IP
|
$16,026.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,083.38 |
| Max. Negotiated Rate |
$15,384.96 |
| Rate for Payer: Aetna Commercial |
$12,340.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,500.28
|
| Rate for Payer: Cash Price |
$8,013.00
|
| Rate for Payer: Cigna Commercial |
$13,301.58
|
| Rate for Payer: First Health Commercial |
$15,224.70
|
| Rate for Payer: Humana Commercial |
$13,622.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,141.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,827.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,807.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,102.88
|
| Rate for Payer: Ohio Health Group HMO |
$12,019.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,205.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,083.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,968.06
|
| Rate for Payer: PHCS Commercial |
$15,384.96
|
| Rate for Payer: United Healthcare All Payer |
$14,102.88
|
|
|
INTERSTIM LEAD KIT 3889-28
|
Facility
|
IP
|
$16,998.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,209.74 |
| Max. Negotiated Rate |
$16,318.08 |
| Rate for Payer: Aetna Commercial |
$13,088.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,258.44
|
| Rate for Payer: Cash Price |
$8,499.00
|
| Rate for Payer: Cigna Commercial |
$14,108.34
|
| Rate for Payer: First Health Commercial |
$16,148.10
|
| Rate for Payer: Humana Commercial |
$14,448.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,938.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,544.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,099.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,958.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,748.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,399.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,209.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,269.38
|
| Rate for Payer: PHCS Commercial |
$16,318.08
|
| Rate for Payer: United Healthcare All Payer |
$14,958.24
|
|
|
INTERSTIM LEAD KIT 3889-28
|
Facility
|
OP
|
$16,998.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,209.74 |
| Max. Negotiated Rate |
$16,318.08 |
| Rate for Payer: Aetna Commercial |
$13,088.46
|
| Rate for Payer: Anthem Medicaid |
$5,845.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,258.44
|
| Rate for Payer: Cash Price |
$8,499.00
|
| Rate for Payer: Cigna Commercial |
$14,108.34
|
| Rate for Payer: First Health Commercial |
$16,148.10
|
| Rate for Payer: Humana Commercial |
$14,448.30
|
| Rate for Payer: Humana KY Medicaid |
$5,845.61
|
| Rate for Payer: Kentucky WC Medicaid |
$5,905.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,938.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,544.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,099.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,962.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,958.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,748.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,399.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,209.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,269.38
|
| Rate for Payer: PHCS Commercial |
$16,318.08
|
| Rate for Payer: United Healthcare All Payer |
$14,958.24
|
|
|
INTERSTIM LEAD KIT 3889-33
|
Facility
|
IP
|
$16,998.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,209.74 |
| Max. Negotiated Rate |
$16,318.08 |
| Rate for Payer: Aetna Commercial |
$13,088.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,258.44
|
| Rate for Payer: Cash Price |
$8,499.00
|
| Rate for Payer: Cigna Commercial |
$14,108.34
|
| Rate for Payer: First Health Commercial |
$16,148.10
|
| Rate for Payer: Humana Commercial |
$14,448.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,938.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,544.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,099.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,958.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,748.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,399.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,209.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,269.38
|
| Rate for Payer: PHCS Commercial |
$16,318.08
|
| Rate for Payer: United Healthcare All Payer |
$14,958.24
|
|
|
INTERSTIM LEAD KIT 3889-33
|
Facility
|
OP
|
$16,998.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,209.74 |
| Max. Negotiated Rate |
$16,318.08 |
| Rate for Payer: Aetna Commercial |
$13,088.46
|
| Rate for Payer: Anthem Medicaid |
$5,845.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,258.44
|
| Rate for Payer: Cash Price |
$8,499.00
|
| Rate for Payer: Cigna Commercial |
$14,108.34
|
| Rate for Payer: First Health Commercial |
$16,148.10
|
| Rate for Payer: Humana Commercial |
$14,448.30
|
| Rate for Payer: Humana KY Medicaid |
$5,845.61
|
| Rate for Payer: Kentucky WC Medicaid |
$5,905.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,938.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,544.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,099.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,962.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,958.24
|
| Rate for Payer: Ohio Health Group HMO |
$12,748.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,399.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,209.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,269.38
|
| Rate for Payer: PHCS Commercial |
$16,318.08
|
| Rate for Payer: United Healthcare All Payer |
$14,958.24
|
|
|
INTERSTIM SMART PROGRAMMER
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
INTERSTIM SMART PROGRAMMER
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
INTERSTIM X SSMRI
|
Facility
|
IP
|
$82,922.74
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,779.96 |
| Max. Negotiated Rate |
$79,605.83 |
| Rate for Payer: Aetna Commercial |
$63,850.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64,679.74
|
| Rate for Payer: Cash Price |
$41,461.37
|
| Rate for Payer: Cigna Commercial |
$68,825.87
|
| Rate for Payer: First Health Commercial |
$78,776.60
|
| Rate for Payer: Humana Commercial |
$70,484.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67,996.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,196.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,876.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$72,972.01
|
| Rate for Payer: Ohio Health Group HMO |
$62,192.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,584.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,779.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,706.05
|
| Rate for Payer: PHCS Commercial |
$79,605.83
|
| Rate for Payer: United Healthcare All Payer |
$72,972.01
|
|
|
INTERSTIM X SSMRI
|
Facility
|
OP
|
$82,922.74
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,779.96 |
| Max. Negotiated Rate |
$79,605.83 |
| Rate for Payer: Aetna Commercial |
$63,850.51
|
| Rate for Payer: Anthem Medicaid |
$28,517.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$64,679.74
|
| Rate for Payer: Cash Price |
$41,461.37
|
| Rate for Payer: Cigna Commercial |
$68,825.87
|
| Rate for Payer: First Health Commercial |
$78,776.60
|
| Rate for Payer: Humana Commercial |
$70,484.33
|
| Rate for Payer: Humana KY Medicaid |
$28,517.13
|
| Rate for Payer: Kentucky WC Medicaid |
$28,807.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$67,996.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,196.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,876.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,089.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$72,972.01
|
| Rate for Payer: Ohio Health Group HMO |
$62,192.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,584.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,779.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,706.05
|
| Rate for Payer: PHCS Commercial |
$79,605.83
|
| Rate for Payer: United Healthcare All Payer |
$72,972.01
|
|
|
INTERSTITIAL LUNG DISEASE WITH CC
|
Facility
|
IP
|
$11,668.97
|
|
|
Service Code
|
MSDRG 197
|
| Min. Negotiated Rate |
$7,918.23 |
| Max. Negotiated Rate |
$11,668.97 |
| Rate for Payer: Anthem Medicaid |
$7,918.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,334.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11,668.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,252.22
|
| Rate for Payer: Humana KY Medicaid |
$7,918.23
|
| Rate for Payer: Humana Medicare Advantage |
$8,334.98
|
| Rate for Payer: Kentucky WC Medicaid |
$7,997.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,001.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,076.60
|
|
|
INTERSTITIAL LUNG DISEASE WITH MCC
|
Facility
|
IP
|
$22,172.77
|
|
|
Service Code
|
MSDRG 196
|
| Min. Negotiated Rate |
$15,045.81 |
| Max. Negotiated Rate |
$22,172.77 |
| Rate for Payer: Anthem Medicaid |
$15,045.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,837.69
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22,172.77
|
| Rate for Payer: CareSource Just4Me Medicare |
$21,380.88
|
| Rate for Payer: Humana KY Medicaid |
$15,045.81
|
| Rate for Payer: Humana Medicare Advantage |
$15,837.69
|
| Rate for Payer: Kentucky WC Medicaid |
$15,196.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19,005.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,346.72
|
|
|
INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC
|
Facility
|
IP
|
$9,103.54
|
|
|
Service Code
|
MSDRG 198
|
| Min. Negotiated Rate |
$6,177.40 |
| Max. Negotiated Rate |
$9,103.54 |
| Rate for Payer: Anthem Medicaid |
$6,177.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,502.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,103.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,778.42
|
| Rate for Payer: Humana KY Medicaid |
$6,177.40
|
| Rate for Payer: Humana Medicare Advantage |
$6,502.53
|
| Rate for Payer: Kentucky WC Medicaid |
$6,239.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,803.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,300.95
|
|
|
INTHRILL SHEATH
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
INTHRILL SHEATH
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
INTHRILL THROMBECTOMY CATH.
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
INTHRILL THROMBECTOMY CATH.
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
