|
INTERSTIM LEAD INTRODUCER KIT
|
Facility
|
OP
|
$3,050.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$915.00 |
| Max. Negotiated Rate |
$2,928.00 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem Medicaid |
$1,048.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$2,531.50
|
| Rate for Payer: First Health Commercial |
$2,897.50
|
| Rate for Payer: Humana Commercial |
$2,592.50
|
| Rate for Payer: Humana KY Medicaid |
$1,048.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,059.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,501.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,250.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$915.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,069.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,684.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,287.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,653.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,104.50
|
| Rate for Payer: PHCS Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare All Payer |
$2,684.00
|
|
|
INTERSTIM LEAD KIT 3093-28
|
Facility
|
OP
|
$16,554.50
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,966.35 |
| Max. Negotiated Rate |
$15,892.32 |
| Rate for Payer: Aetna Commercial |
$12,746.97
|
| Rate for Payer: Anthem Medicaid |
$5,693.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,912.51
|
| Rate for Payer: Cash Price |
$8,277.25
|
| Rate for Payer: Cigna Commercial |
$13,740.24
|
| Rate for Payer: First Health Commercial |
$15,726.77
|
| Rate for Payer: Humana Commercial |
$14,071.33
|
| Rate for Payer: Humana KY Medicaid |
$5,693.09
|
| Rate for Payer: Kentucky WC Medicaid |
$5,751.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,574.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,217.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,966.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,807.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,567.96
|
| Rate for Payer: Ohio Health Group HMO |
$12,415.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,243.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,402.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,422.60
|
| Rate for Payer: PHCS Commercial |
$15,892.32
|
| Rate for Payer: United Healthcare All Payer |
$14,567.96
|
|
|
INTERSTIM LEAD KIT 3093-28
|
Facility
|
IP
|
$16,554.50
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,966.35 |
| Max. Negotiated Rate |
$15,892.32 |
| Rate for Payer: Aetna Commercial |
$12,746.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,912.51
|
| Rate for Payer: Cash Price |
$8,277.25
|
| Rate for Payer: Cigna Commercial |
$13,740.24
|
| Rate for Payer: First Health Commercial |
$15,726.77
|
| Rate for Payer: Humana Commercial |
$14,071.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,574.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,217.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,966.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,567.96
|
| Rate for Payer: Ohio Health Group HMO |
$12,415.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,243.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,402.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,422.60
|
| Rate for Payer: PHCS Commercial |
$15,892.32
|
| Rate for Payer: United Healthcare All Payer |
$14,567.96
|
|
|
INTERSTIM LEAD KIT 3889-28
|
Facility
|
OP
|
$17,553.50
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,266.05 |
| Max. Negotiated Rate |
$16,851.36 |
| Rate for Payer: Aetna Commercial |
$13,516.19
|
| Rate for Payer: Anthem Medicaid |
$6,036.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,691.73
|
| Rate for Payer: Cash Price |
$8,776.75
|
| Rate for Payer: Cigna Commercial |
$14,569.41
|
| Rate for Payer: First Health Commercial |
$16,675.83
|
| Rate for Payer: Humana Commercial |
$14,920.48
|
| Rate for Payer: Humana KY Medicaid |
$6,036.65
|
| Rate for Payer: Kentucky WC Medicaid |
$6,098.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,393.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,954.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,266.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,157.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,447.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,165.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,042.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,271.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,111.92
|
| Rate for Payer: PHCS Commercial |
$16,851.36
|
| Rate for Payer: United Healthcare All Payer |
$15,447.08
|
|
|
INTERSTIM LEAD KIT 3889-28
|
Facility
|
IP
|
$17,553.50
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,266.05 |
| Max. Negotiated Rate |
$16,851.36 |
| Rate for Payer: Aetna Commercial |
$13,516.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,691.73
|
| Rate for Payer: Cash Price |
$8,776.75
|
| Rate for Payer: Cigna Commercial |
$14,569.41
|
| Rate for Payer: First Health Commercial |
$16,675.83
|
| Rate for Payer: Humana Commercial |
$14,920.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,393.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,954.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,266.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,447.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,165.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,042.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,271.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,111.92
|
| Rate for Payer: PHCS Commercial |
$16,851.36
|
| Rate for Payer: United Healthcare All Payer |
$15,447.08
|
|
|
INTERSTIM LEAD KIT 3889-33
|
Facility
|
IP
|
$17,553.50
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,266.05 |
| Max. Negotiated Rate |
$16,851.36 |
| Rate for Payer: Aetna Commercial |
$13,516.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,691.73
|
| Rate for Payer: Cash Price |
$8,776.75
|
| Rate for Payer: Cigna Commercial |
$14,569.41
|
| Rate for Payer: First Health Commercial |
$16,675.83
|
| Rate for Payer: Humana Commercial |
$14,920.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,393.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,954.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,266.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,447.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,165.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,042.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,271.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,111.92
|
| Rate for Payer: PHCS Commercial |
$16,851.36
|
| Rate for Payer: United Healthcare All Payer |
$15,447.08
|
|
|
INTERSTIM LEAD KIT 3889-33
|
Facility
|
OP
|
$17,553.50
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,266.05 |
| Max. Negotiated Rate |
$16,851.36 |
| Rate for Payer: Aetna Commercial |
$13,516.19
|
| Rate for Payer: Anthem Medicaid |
$6,036.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,691.73
|
| Rate for Payer: Cash Price |
$8,776.75
|
| Rate for Payer: Cigna Commercial |
$14,569.41
|
| Rate for Payer: First Health Commercial |
$16,675.83
|
| Rate for Payer: Humana Commercial |
$14,920.48
|
| Rate for Payer: Humana KY Medicaid |
$6,036.65
|
| Rate for Payer: Kentucky WC Medicaid |
$6,098.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,393.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,954.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,266.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,157.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,447.08
|
| Rate for Payer: Ohio Health Group HMO |
$13,165.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,042.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,271.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,111.92
|
| Rate for Payer: PHCS Commercial |
$16,851.36
|
| Rate for Payer: United Healthcare All Payer |
$15,447.08
|
|
|
INTERSTIM SMART PROGRAMMER
|
Facility
|
OP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem Medicaid |
$3,479.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Humana KY Medicaid |
$3,479.41
|
| Rate for Payer: Kentucky WC Medicaid |
$3,514.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,549.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
INTERSTIM SMART PROGRAMMER
|
Facility
|
IP
|
$10,117.50
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,035.25 |
| Max. Negotiated Rate |
$9,712.80 |
| Rate for Payer: Aetna Commercial |
$7,790.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,891.65
|
| Rate for Payer: Cash Price |
$5,058.75
|
| Rate for Payer: Cigna Commercial |
$8,397.52
|
| Rate for Payer: First Health Commercial |
$9,611.62
|
| Rate for Payer: Humana Commercial |
$8,599.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,296.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,466.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,035.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,903.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,588.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,094.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,802.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,981.07
|
| Rate for Payer: PHCS Commercial |
$9,712.80
|
| Rate for Payer: United Healthcare All Payer |
$8,903.40
|
|
|
INTERSTIM X SSMRI
|
Facility
|
IP
|
$70,597.00
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,179.10 |
| Max. Negotiated Rate |
$67,773.12 |
| Rate for Payer: Aetna Commercial |
$54,359.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,065.66
|
| Rate for Payer: Cash Price |
$35,298.50
|
| Rate for Payer: Cigna Commercial |
$58,595.51
|
| Rate for Payer: First Health Commercial |
$67,067.15
|
| Rate for Payer: Humana Commercial |
$60,007.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,889.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,100.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,179.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,125.36
|
| Rate for Payer: Ohio Health Group HMO |
$52,947.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56,477.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61,419.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48,711.93
|
| Rate for Payer: PHCS Commercial |
$67,773.12
|
| Rate for Payer: United Healthcare All Payer |
$62,125.36
|
|
|
INTERSTIM X SSMRI
|
Facility
|
OP
|
$70,597.00
|
|
|
Service Code
|
HCPCS C1767
|
| Hospital Charge Code |
27000081
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$21,179.10 |
| Max. Negotiated Rate |
$67,773.12 |
| Rate for Payer: Aetna Commercial |
$54,359.69
|
| Rate for Payer: Anthem Medicaid |
$24,278.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55,065.66
|
| Rate for Payer: Cash Price |
$35,298.50
|
| Rate for Payer: Cigna Commercial |
$58,595.51
|
| Rate for Payer: First Health Commercial |
$67,067.15
|
| Rate for Payer: Humana Commercial |
$60,007.45
|
| Rate for Payer: Humana KY Medicaid |
$24,278.31
|
| Rate for Payer: Kentucky WC Medicaid |
$24,525.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,889.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$52,100.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,179.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,765.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$62,125.36
|
| Rate for Payer: Ohio Health Group HMO |
$52,947.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$56,477.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61,419.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$48,711.93
|
| Rate for Payer: PHCS Commercial |
$67,773.12
|
| Rate for Payer: United Healthcare All Payer |
$62,125.36
|
|
|
INTHRILL SHEATH
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
INTHRILL SHEATH
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
INTHRILL THROMBECTOMY CATH.
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
INTHRILL THROMBECTOMY CATH.
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Facility
|
IP
|
$1,062.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
45000069
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$318.60 |
| Max. Negotiated Rate |
$1,019.52 |
| Rate for Payer: Aetna Commercial |
$817.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$828.36
|
| Rate for Payer: Cash Price |
$531.00
|
| Rate for Payer: Cigna Commercial |
$881.46
|
| Rate for Payer: First Health Commercial |
$1,008.90
|
| Rate for Payer: Humana Commercial |
$902.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$870.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$783.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$318.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$934.56
|
| Rate for Payer: Ohio Health Group HMO |
$796.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$732.78
|
| Rate for Payer: PHCS Commercial |
$1,019.52
|
| Rate for Payer: United Healthcare All Payer |
$934.56
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Facility
|
IP
|
$1,737.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
76100147
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$521.10 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$521.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Facility
|
OP
|
$1,737.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
76100147
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| Max. Negotiated Rate |
$1,667.52 |
| Rate for Payer: Aetna Commercial |
$1,337.49
|
| Rate for Payer: Anthem Medicaid |
$597.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,354.86
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$1,441.71
|
| Rate for Payer: First Health Commercial |
$1,650.15
|
| Rate for Payer: Humana Commercial |
$1,476.45
|
| Rate for Payer: Humana KY Medicaid |
$597.35
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$603.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,424.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,281.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$609.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,528.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,302.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,389.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,511.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,198.53
|
| Rate for Payer: PHCS Commercial |
$1,667.52
|
| Rate for Payer: United Healthcare All Payer |
$1,528.56
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Facility
|
OP
|
$1,062.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
45000069
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$365.22 |
| Max. Negotiated Rate |
$1,019.52 |
| Rate for Payer: Aetna Commercial |
$817.74
|
| Rate for Payer: Anthem Medicaid |
$365.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$828.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$531.00
|
| Rate for Payer: Cash Price |
$531.00
|
| Rate for Payer: Cigna Commercial |
$881.46
|
| Rate for Payer: First Health Commercial |
$1,008.90
|
| Rate for Payer: Humana Commercial |
$902.70
|
| Rate for Payer: Humana KY Medicaid |
$365.22
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$368.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$870.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$783.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$372.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$934.56
|
| Rate for Payer: Ohio Health Group HMO |
$796.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$732.78
|
| Rate for Payer: PHCS Commercial |
$1,019.52
|
| Rate for Payer: United Healthcare All Payer |
$934.56
|
|
|
INTMD RPR FACE/MM 12.6-20 CM
|
Professional
|
Both
|
$1,737.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
76100147
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$151.75 |
| Max. Negotiated Rate |
$1,042.20 |
| Rate for Payer: Aetna Commercial |
$402.35
|
| Rate for Payer: Ambetter Exchange |
$284.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$151.75
|
| Rate for Payer: Anthem Medicaid |
$224.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$284.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$284.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$340.86
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cash Price |
$868.50
|
| Rate for Payer: Cigna Commercial |
$378.53
|
| Rate for Payer: Healthspan PPO |
$469.36
|
| Rate for Payer: Humana Medicaid |
$224.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$341.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$284.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.91
|
| Rate for Payer: Molina Healthcare Passport |
$224.42
|
| Rate for Payer: Multiplan PHCS |
$1,042.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.26
|
| Rate for Payer: UHCCP Medicaid |
$159.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$226.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$284.05
|
|
|
INTMD RPR FACE/MM 12.6-20 C(P
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
761P0147
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$151.75 |
| Max. Negotiated Rate |
$469.36 |
| Rate for Payer: Aetna Commercial |
$402.35
|
| Rate for Payer: Ambetter Exchange |
$284.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$151.75
|
| Rate for Payer: Anthem Medicaid |
$224.42
|
| Rate for Payer: Buckeye Individual/Medicaid |
$284.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$284.05
|
| Rate for Payer: CareSource Just4Me Medicare |
$340.86
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$378.53
|
| Rate for Payer: Healthspan PPO |
$469.36
|
| Rate for Payer: Humana Medicaid |
$224.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$341.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$284.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.05
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$228.91
|
| Rate for Payer: Molina Healthcare Passport |
$224.42
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$369.26
|
| Rate for Payer: UHCCP Medicaid |
$159.34
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$226.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$284.05
|
|
|
INTMD RPR FACE/MM 12.6-20 C(T
|
Facility
|
OP
|
$1,062.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
761T0147
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$365.22 |
| Max. Negotiated Rate |
$1,019.52 |
| Rate for Payer: Aetna Commercial |
$817.74
|
| Rate for Payer: Anthem Medicaid |
$365.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$828.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$531.00
|
| Rate for Payer: Cash Price |
$531.00
|
| Rate for Payer: Cigna Commercial |
$881.46
|
| Rate for Payer: First Health Commercial |
$1,008.90
|
| Rate for Payer: Humana Commercial |
$902.70
|
| Rate for Payer: Humana KY Medicaid |
$365.22
|
| Rate for Payer: Humana Medicare Advantage |
$369.16
|
| Rate for Payer: Kentucky WC Medicaid |
$368.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$870.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$783.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$372.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$934.56
|
| Rate for Payer: Ohio Health Group HMO |
$796.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$732.78
|
| Rate for Payer: PHCS Commercial |
$1,019.52
|
| Rate for Payer: United Healthcare All Payer |
$934.56
|
|
|
INTMD RPR FACE/MM 12.6-20 C(T
|
Facility
|
IP
|
$1,062.00
|
|
|
Service Code
|
HCPCS 12055
|
| Hospital Charge Code |
761T0147
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$318.60 |
| Max. Negotiated Rate |
$1,019.52 |
| Rate for Payer: Aetna Commercial |
$817.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$828.36
|
| Rate for Payer: Cash Price |
$531.00
|
| Rate for Payer: Cigna Commercial |
$881.46
|
| Rate for Payer: First Health Commercial |
$1,008.90
|
| Rate for Payer: Humana Commercial |
$902.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$870.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$783.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$318.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$934.56
|
| Rate for Payer: Ohio Health Group HMO |
$796.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$849.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$923.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$732.78
|
| Rate for Payer: PHCS Commercial |
$1,019.52
|
| Rate for Payer: United Healthcare All Payer |
$934.56
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
76102580
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$369.16 |
| 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 Medicare Advantage/PPO |
$369.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$498.37
|
| Rate for Payer: Cash Price |
$840.00
|
| 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: Humana Medicare Advantage |
$369.16
|
| 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 |
$442.99
|
| 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
|
|
|
INTMD RPR FACE/MM >30.0 CM
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS 12057
|
| Hospital Charge Code |
76102580
|
|
Hospital Revenue Code
|
761
|
| 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
|
|
