|
KYLEENA IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
63600069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
KYLEENA IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
25002481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
KYLEENA IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
25002481
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
KYLEENA IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
636T0069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
KYLEENA IUD
|
Professional
|
Both
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
63600069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$612.50 |
| Max. Negotiated Rate |
$1,750.00 |
| Rate for Payer: Aetna Commercial |
$1,366.87
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,750.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,433.29
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,225.00
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
|
|
KYLEENA IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
63600069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.82
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
KYLEENA IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
636T0069
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.50 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$542.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
KYPHOPLAS EA ADD'L VERT BODY(P
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 22515
|
| Hospital Charge Code |
761P0426
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.11 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$169.11
|
| Rate for Payer: Anthem Medicaid |
$184.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.00
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$432.51
|
| Rate for Payer: Humana Medicaid |
$184.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$300.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$187.92
|
| Rate for Payer: Molina Healthcare Passport |
$184.24
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.50
|
| Rate for Payer: UHCCP Medicaid |
$177.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.08
|
|
|
KYPHOPLASTY EA ADD'L VERT BODY
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
HCPCS 22515
|
| Hospital Charge Code |
76100426
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$370.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: First Health Commercial |
$451.25
|
| Rate for Payer: Humana Commercial |
$403.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$389.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$350.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.00
|
| Rate for Payer: Ohio Health Group HMO |
$356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.25
|
| Rate for Payer: PHCS Commercial |
$456.00
|
| Rate for Payer: United Healthcare All Payer |
$418.00
|
|
|
KYPHOPLASTY EA ADD'L VERT BODY
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
HCPCS 22515
|
| Hospital Charge Code |
76100426
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$61.75 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna Commercial |
$365.75
|
| Rate for Payer: Anthem Medicaid |
$163.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$370.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$394.25
|
| Rate for Payer: First Health Commercial |
$451.25
|
| Rate for Payer: Humana Commercial |
$403.75
|
| Rate for Payer: Humana KY Medicaid |
$163.35
|
| Rate for Payer: Kentucky WC Medicaid |
$165.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$389.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$350.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$142.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$166.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$418.00
|
| Rate for Payer: Ohio Health Group HMO |
$356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$95.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$61.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$147.25
|
| Rate for Payer: PHCS Commercial |
$456.00
|
| Rate for Payer: United Healthcare All Payer |
$418.00
|
|
|
KYPHOPLASTY EA ADD'L VERT BODY
|
Professional
|
Both
|
$475.00
|
|
|
Service Code
|
HCPCS 22515
|
| Hospital Charge Code |
76100426
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.11 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$169.11
|
| Rate for Payer: Anthem Medicaid |
$184.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$475.00
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Cigna Commercial |
$432.51
|
| Rate for Payer: Humana Medicaid |
$184.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$300.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$187.92
|
| Rate for Payer: Molina Healthcare Passport |
$184.24
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.50
|
| Rate for Payer: UHCCP Medicaid |
$177.57
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$186.08
|
|
|
KYPHOPLASTY LUMBAR
|
Facility
|
IP
|
$1,015.00
|
|
|
Service Code
|
HCPCS 22514
|
| Hospital Charge Code |
76100425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$131.95 |
| Max. Negotiated Rate |
$974.40 |
| Rate for Payer: Aetna Commercial |
$781.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$791.70
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$842.45
|
| Rate for Payer: First Health Commercial |
$964.25
|
| Rate for Payer: Humana Commercial |
$862.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$832.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$749.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$304.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$893.20
|
| Rate for Payer: Ohio Health Group HMO |
$761.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$314.65
|
| Rate for Payer: PHCS Commercial |
$974.40
|
| Rate for Payer: United Healthcare All Payer |
$893.20
|
|
|
KYPHOPLASTY LUMBAR
|
Facility
|
OP
|
$1,015.00
|
|
|
Service Code
|
HCPCS 22514
|
| Hospital Charge Code |
76100425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$131.95 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$781.55
|
| Rate for Payer: Anthem Medicaid |
$349.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$791.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$842.45
|
| Rate for Payer: First Health Commercial |
$964.25
|
| Rate for Payer: Humana Commercial |
$862.75
|
| Rate for Payer: Humana KY Medicaid |
$349.06
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$352.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$832.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$749.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$356.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$893.20
|
| Rate for Payer: Ohio Health Group HMO |
$761.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$131.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$314.65
|
| Rate for Payer: PHCS Commercial |
$974.40
|
| Rate for Payer: United Healthcare All Payer |
$893.20
|
|
|
KYPHOPLASTY LUMBAR
|
Professional
|
Both
|
$1,015.00
|
|
|
Service Code
|
HCPCS 22514
|
| Hospital Charge Code |
76100425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.84 |
| Max. Negotiated Rate |
$1,015.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$376.84
|
| Rate for Payer: Anthem Medicaid |
$405.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,015.00
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$952.26
|
| Rate for Payer: Humana Medicaid |
$405.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$661.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$413.37
|
| Rate for Payer: Molina Healthcare Passport |
$405.26
|
| Rate for Payer: Multiplan PHCS |
$609.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$710.50
|
| Rate for Payer: UHCCP Medicaid |
$395.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$409.31
|
|
|
KYPHOPLASTY LUMBAR (P
|
Professional
|
Both
|
$1,015.00
|
|
|
Service Code
|
HCPCS 22514
|
| Hospital Charge Code |
761P0425
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.84 |
| Max. Negotiated Rate |
$1,015.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$376.84
|
| Rate for Payer: Anthem Medicaid |
$405.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,015.00
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cash Price |
$507.50
|
| Rate for Payer: Cigna Commercial |
$952.26
|
| Rate for Payer: Humana Medicaid |
$405.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$661.57
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$413.37
|
| Rate for Payer: Molina Healthcare Passport |
$405.26
|
| Rate for Payer: Multiplan PHCS |
$609.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$710.50
|
| Rate for Payer: UHCCP Medicaid |
$395.68
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$409.31
|
|
|
KYPHOPLASTY THORACIC
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22513
|
| Hospital Charge Code |
76100424
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem Medicaid |
$378.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Humana KY Medicaid |
$378.29
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$382.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$385.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
KYPHOPLASTY THORACIC
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22513
|
| Hospital Charge Code |
76100424
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.43 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$403.43
|
| Rate for Payer: Anthem Medicaid |
$435.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,022.33
|
| Rate for Payer: Humana Medicaid |
$435.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$710.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$443.83
|
| Rate for Payer: Molina Healthcare Passport |
$435.13
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$423.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$439.48
|
|
|
KYPHOPLASTY THORACIC
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22513
|
| Hospital Charge Code |
76100424
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$143.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$220.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$143.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$341.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
KYPHOPLASTY THORACIC (P
|
Professional
|
Both
|
$1,100.00
|
|
|
Service Code
|
HCPCS 22513
|
| Hospital Charge Code |
761P0424
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.43 |
| Max. Negotiated Rate |
$1,100.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$403.43
|
| Rate for Payer: Anthem Medicaid |
$435.13
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,100.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$1,022.33
|
| Rate for Payer: Humana Medicaid |
$435.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$710.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$443.83
|
| Rate for Payer: Molina Healthcare Passport |
$435.13
|
| Rate for Payer: Multiplan PHCS |
$660.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$770.00
|
| Rate for Payer: UHCCP Medicaid |
$423.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$439.48
|
|
|
KYPROLIS 10MG VIAL
|
Facility
|
OP
|
$2,974.94
|
|
|
Service Code
|
HCPCS J9047
|
| Hospital Charge Code |
25003885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$2,855.94 |
| Rate for Payer: Aetna Commercial |
$2,290.70
|
| Rate for Payer: Anthem Medicaid |
$1,023.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.56
|
| Rate for Payer: Cash Price |
$1,487.47
|
| Rate for Payer: Cash Price |
$1,487.47
|
| Rate for Payer: Cigna Commercial |
$2,469.20
|
| Rate for Payer: First Health Commercial |
$2,826.19
|
| Rate for Payer: Humana Commercial |
$2,528.70
|
| Rate for Payer: Humana KY Medicaid |
$1,023.08
|
| Rate for Payer: Humana Medicare Advantage |
$47.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,033.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,043.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,617.95
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$594.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$386.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$922.23
|
| Rate for Payer: PHCS Commercial |
$2,855.94
|
| Rate for Payer: United Healthcare All Payer |
$2,617.95
|
|
|
KYPROLIS 10MG VIAL
|
Facility
|
IP
|
$2,974.94
|
|
|
Service Code
|
HCPCS J9047
|
| Hospital Charge Code |
25003885
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$386.74 |
| Max. Negotiated Rate |
$2,855.94 |
| Rate for Payer: First Health Commercial |
$2,826.19
|
| Rate for Payer: Humana Commercial |
$2,528.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,617.95
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$594.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$386.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$922.23
|
| Rate for Payer: PHCS Commercial |
$2,855.94
|
| Rate for Payer: United Healthcare All Payer |
$2,617.95
|
| Rate for Payer: Aetna Commercial |
$2,290.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.45
|
| Rate for Payer: Cash Price |
$1,487.47
|
| Rate for Payer: Cigna Commercial |
$2,469.20
|
|
|
KYPROLIS 1MG [60MG VIAL]
|
Facility
|
OP
|
$17,849.73
|
|
|
Service Code
|
HCPCS J9047
|
| Hospital Charge Code |
25002580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$17,135.74 |
| Rate for Payer: Aetna Commercial |
$13,744.29
|
| Rate for Payer: Anthem Medicaid |
$6,138.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,922.79
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.56
|
| Rate for Payer: Cash Price |
$8,924.86
|
| Rate for Payer: Cash Price |
$8,924.86
|
| Rate for Payer: Cigna Commercial |
$14,815.28
|
| Rate for Payer: First Health Commercial |
$16,957.24
|
| Rate for Payer: Humana Commercial |
$15,172.27
|
| Rate for Payer: Humana KY Medicaid |
$6,138.52
|
| Rate for Payer: Humana Medicare Advantage |
$47.08
|
| Rate for Payer: Kentucky WC Medicaid |
$6,201.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,636.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,173.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,261.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,707.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,387.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,569.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,320.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,533.42
|
| Rate for Payer: PHCS Commercial |
$17,135.74
|
| Rate for Payer: United Healthcare All Payer |
$15,707.76
|
|
|
KYPROLIS 1MG [60MG VIAL]
|
Facility
|
IP
|
$17,849.73
|
|
|
Service Code
|
HCPCS J9047
|
| Hospital Charge Code |
25002580
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,320.46 |
| Max. Negotiated Rate |
$17,135.74 |
| Rate for Payer: Aetna Commercial |
$13,744.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,922.79
|
| Rate for Payer: Cash Price |
$8,924.86
|
| Rate for Payer: Cigna Commercial |
$14,815.28
|
| Rate for Payer: First Health Commercial |
$16,957.24
|
| Rate for Payer: Humana Commercial |
$15,172.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,636.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,173.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,354.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,707.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,387.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,569.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,320.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,533.42
|
| Rate for Payer: PHCS Commercial |
$17,135.74
|
| Rate for Payer: United Healthcare All Payer |
$15,707.76
|
|
|
KYPROLIS 30MG VIAL
|
Facility
|
OP
|
$8,924.87
|
|
|
Service Code
|
HCPCS J9047
|
| Hospital Charge Code |
25002579
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.08 |
| Max. Negotiated Rate |
$8,567.88 |
| Rate for Payer: Aetna Commercial |
$6,872.15
|
| Rate for Payer: Anthem Medicaid |
$3,069.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$47.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,961.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$65.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$63.56
|
| Rate for Payer: Cash Price |
$4,462.44
|
| Rate for Payer: Cash Price |
$4,462.44
|
| Rate for Payer: Cigna Commercial |
$7,407.64
|
| Rate for Payer: First Health Commercial |
$8,478.63
|
| Rate for Payer: Humana Commercial |
$7,586.14
|
| Rate for Payer: Humana KY Medicaid |
$3,069.26
|
| Rate for Payer: Humana Medicare Advantage |
$47.08
|
| Rate for Payer: Kentucky WC Medicaid |
$3,100.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,318.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,586.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,130.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,853.89
|
| Rate for Payer: Ohio Health Group HMO |
$6,693.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,784.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,160.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,766.71
|
| Rate for Payer: PHCS Commercial |
$8,567.88
|
| Rate for Payer: United Healthcare All Payer |
$7,853.89
|
|
|
KYPROLIS 30MG VIAL
|
Facility
|
IP
|
$8,924.87
|
|
|
Service Code
|
HCPCS J9047
|
| Hospital Charge Code |
25002579
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,160.23 |
| Max. Negotiated Rate |
$8,567.88 |
| Rate for Payer: Aetna Commercial |
$6,872.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,961.40
|
| Rate for Payer: Cash Price |
$4,462.44
|
| Rate for Payer: Cigna Commercial |
$7,407.64
|
| Rate for Payer: First Health Commercial |
$8,478.63
|
| Rate for Payer: Humana Commercial |
$7,586.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,318.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,586.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,677.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,853.89
|
| Rate for Payer: Ohio Health Group HMO |
$6,693.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,784.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,160.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,766.71
|
| Rate for Payer: PHCS Commercial |
$8,567.88
|
| Rate for Payer: United Healthcare All Payer |
$7,853.89
|
|
