|
LEAD VENT AROX 338 021
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
27000068
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem Medicaid |
$1,358.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Humana KY Medicaid |
$1,358.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,372.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
LEAD VENT KENTROX SL 347 351
|
Facility
|
IP
|
$16,800.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,184.00 |
| Max. Negotiated Rate |
$16,128.00 |
| Rate for Payer: Aetna Commercial |
$12,936.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,104.00
|
| Rate for Payer: Cash Price |
$8,400.00
|
| Rate for Payer: Cigna Commercial |
$13,944.00
|
| Rate for Payer: First Health Commercial |
$15,960.00
|
| Rate for Payer: Humana Commercial |
$14,280.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,776.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,398.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,040.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,184.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,208.00
|
| Rate for Payer: PHCS Commercial |
$16,128.00
|
| Rate for Payer: United Healthcare All Payer |
$14,784.00
|
|
|
LEAD VENT KENTROX SL 347 351
|
Facility
|
OP
|
$16,800.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,184.00 |
| Max. Negotiated Rate |
$16,128.00 |
| Rate for Payer: Aetna Commercial |
$12,936.00
|
| Rate for Payer: Anthem Medicaid |
$5,777.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,104.00
|
| Rate for Payer: Cash Price |
$8,400.00
|
| Rate for Payer: Cigna Commercial |
$13,944.00
|
| Rate for Payer: First Health Commercial |
$15,960.00
|
| Rate for Payer: Humana Commercial |
$14,280.00
|
| Rate for Payer: Humana KY Medicaid |
$5,777.52
|
| Rate for Payer: Kentucky WC Medicaid |
$5,836.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,776.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,398.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,040.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,893.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$12,600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,184.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,208.00
|
| Rate for Payer: PHCS Commercial |
$16,128.00
|
| Rate for Payer: United Healthcare All Payer |
$14,784.00
|
|
|
LEAD VENTRICAL 1570/65
|
Facility
|
OP
|
$20,312.50
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,640.62 |
| Max. Negotiated Rate |
$19,500.00 |
| Rate for Payer: Aetna Commercial |
$15,640.62
|
| Rate for Payer: Anthem Medicaid |
$6,985.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,843.75
|
| Rate for Payer: Cash Price |
$10,156.25
|
| Rate for Payer: Cigna Commercial |
$16,859.38
|
| Rate for Payer: First Health Commercial |
$19,296.88
|
| Rate for Payer: Humana Commercial |
$17,265.62
|
| Rate for Payer: Humana KY Medicaid |
$6,985.47
|
| Rate for Payer: Kentucky WC Medicaid |
$7,056.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,656.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,990.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,093.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,125.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,875.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,234.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,062.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,640.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,296.88
|
| Rate for Payer: PHCS Commercial |
$19,500.00
|
| Rate for Payer: United Healthcare All Payer |
$17,875.00
|
|
|
LEAD VENTRICAL 1570/65
|
Facility
|
IP
|
$20,312.50
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,640.62 |
| Max. Negotiated Rate |
$19,500.00 |
| Rate for Payer: Aetna Commercial |
$15,640.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,843.75
|
| Rate for Payer: Cash Price |
$10,156.25
|
| Rate for Payer: Cigna Commercial |
$16,859.38
|
| Rate for Payer: First Health Commercial |
$19,296.88
|
| Rate for Payer: Humana Commercial |
$17,265.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,656.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,990.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,093.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,875.00
|
| Rate for Payer: Ohio Health Group HMO |
$15,234.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,062.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,640.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,296.88
|
| Rate for Payer: PHCS Commercial |
$19,500.00
|
| Rate for Payer: United Healthcare All Payer |
$17,875.00
|
|
|
LEAD VENTRICAL SILICON 5071-35
|
Facility
|
IP
|
$3,530.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$458.90 |
| Max. Negotiated Rate |
$3,388.80 |
| Rate for Payer: Aetna Commercial |
$2,718.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.40
|
| Rate for Payer: Cash Price |
$1,765.00
|
| Rate for Payer: Cigna Commercial |
$2,929.90
|
| Rate for Payer: First Health Commercial |
$3,353.50
|
| Rate for Payer: Humana Commercial |
$3,000.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$706.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.30
|
| Rate for Payer: PHCS Commercial |
$3,388.80
|
| Rate for Payer: United Healthcare All Payer |
$3,106.40
|
|
|
LEAD VENTRICAL SILICON 5071-35
|
Facility
|
OP
|
$3,530.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$458.90 |
| Max. Negotiated Rate |
$3,388.80 |
| Rate for Payer: Aetna Commercial |
$2,718.10
|
| Rate for Payer: Anthem Medicaid |
$1,213.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.40
|
| Rate for Payer: Cash Price |
$1,765.00
|
| Rate for Payer: Cigna Commercial |
$2,929.90
|
| Rate for Payer: First Health Commercial |
$3,353.50
|
| Rate for Payer: Humana Commercial |
$3,000.50
|
| Rate for Payer: Humana KY Medicaid |
$1,213.97
|
| Rate for Payer: Kentucky WC Medicaid |
$1,226.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,238.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$706.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.30
|
| Rate for Payer: PHCS Commercial |
$3,388.80
|
| Rate for Payer: United Healthcare All Payer |
$3,106.40
|
|
|
LEAD VENTRICULAR 4592-52
|
Facility
|
IP
|
$3,530.00
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
27000068
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$458.90 |
| Max. Negotiated Rate |
$3,388.80 |
| Rate for Payer: Aetna Commercial |
$2,718.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.40
|
| Rate for Payer: Cash Price |
$1,765.00
|
| Rate for Payer: Cigna Commercial |
$2,929.90
|
| Rate for Payer: First Health Commercial |
$3,353.50
|
| Rate for Payer: Humana Commercial |
$3,000.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$706.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.30
|
| Rate for Payer: PHCS Commercial |
$3,388.80
|
| Rate for Payer: United Healthcare All Payer |
$3,106.40
|
|
|
LEAD VENTRICULAR 4592-52
|
Facility
|
OP
|
$3,530.00
|
|
|
Service Code
|
HCPCS C1900
|
| Hospital Charge Code |
27000068
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$458.90 |
| Max. Negotiated Rate |
$3,388.80 |
| Rate for Payer: Aetna Commercial |
$2,718.10
|
| Rate for Payer: Anthem Medicaid |
$1,213.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.40
|
| Rate for Payer: Cash Price |
$1,765.00
|
| Rate for Payer: Cigna Commercial |
$2,929.90
|
| Rate for Payer: First Health Commercial |
$3,353.50
|
| Rate for Payer: Humana Commercial |
$3,000.50
|
| Rate for Payer: Humana KY Medicaid |
$1,213.97
|
| Rate for Payer: Kentucky WC Medicaid |
$1,226.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,238.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$706.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,094.30
|
| Rate for Payer: PHCS Commercial |
$3,388.80
|
| Rate for Payer: United Healthcare All Payer |
$3,106.40
|
|
|
LEAD VENT SELOX 343 083
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem Medicaid |
$1,358.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Humana KY Medicaid |
$1,358.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,372.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
LEAD VENT SELOX 343 083
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
LEFORT I-2 PIECE W/O GRAFT
|
Professional
|
Both
|
$4,300.00
|
|
|
Service Code
|
HCPCS 21142
|
| Hospital Charge Code |
76100374
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$956.18 |
| Max. Negotiated Rate |
$4,300.00 |
| Rate for Payer: Aetna Commercial |
$1,951.91
|
| Rate for Payer: Anthem Medicaid |
$956.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,300.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$2,117.94
|
| Rate for Payer: Healthspan PPO |
$1,768.01
|
| Rate for Payer: Humana Medicaid |
$956.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,739.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$975.30
|
| Rate for Payer: Molina Healthcare Passport |
$956.18
|
| Rate for Payer: Multiplan PHCS |
$2,580.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,010.00
|
| Rate for Payer: UHCCP Medicaid |
$1,505.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.74
|
|
|
LEFORT I-2 PIECE W/O GRAFT
|
Facility
|
OP
|
$4,300.00
|
|
|
Service Code
|
HCPCS 21142
|
| Hospital Charge Code |
76100374
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$7,089.80 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem Medicaid |
$1,478.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,064.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,089.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,836.59
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Humana KY Medicaid |
$1,478.77
|
| Rate for Payer: Humana Medicare Advantage |
$5,064.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,493.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,076.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,508.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEFORT I-2 PIECE W/O GRAFT
|
Facility
|
IP
|
$4,300.00
|
|
|
Service Code
|
HCPCS 21142
|
| Hospital Charge Code |
76100374
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$559.00 |
| Max. Negotiated Rate |
$4,128.00 |
| Rate for Payer: Aetna Commercial |
$3,311.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,354.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$3,569.00
|
| Rate for Payer: First Health Commercial |
$4,085.00
|
| Rate for Payer: Humana Commercial |
$3,655.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,526.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,173.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,784.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,225.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$559.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,333.00
|
| Rate for Payer: PHCS Commercial |
$4,128.00
|
| Rate for Payer: United Healthcare All Payer |
$3,784.00
|
|
|
LEFORT I-2 PIECE W/O GRAFT(P
|
Professional
|
Both
|
$4,300.00
|
|
|
Service Code
|
HCPCS 21142
|
| Hospital Charge Code |
761P0374
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$956.18 |
| Max. Negotiated Rate |
$4,300.00 |
| Rate for Payer: Aetna Commercial |
$1,951.91
|
| Rate for Payer: Anthem Medicaid |
$956.18
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,300.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cash Price |
$2,150.00
|
| Rate for Payer: Cigna Commercial |
$2,117.94
|
| Rate for Payer: Healthspan PPO |
$1,768.01
|
| Rate for Payer: Humana Medicaid |
$956.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,739.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$975.30
|
| Rate for Payer: Molina Healthcare Passport |
$956.18
|
| Rate for Payer: Multiplan PHCS |
$2,580.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,010.00
|
| Rate for Payer: UHCCP Medicaid |
$1,505.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.74
|
|
|
LEFT ANTEVERTED MOD NECK
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
LEFT ANTEVERTED MOD NECK
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem Medicaid |
$1,358.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Humana KY Medicaid |
$1,358.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,372.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
LEFT BREAST SURGERY
|
Professional
|
Both
|
$790.00
|
|
| Hospital Charge Code |
22200367
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$276.50 |
| Max. Negotiated Rate |
$790.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$790.00
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Multiplan PHCS |
$474.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$553.00
|
| Rate for Payer: UHCCP Medicaid |
$276.50
|
|
|
LEFT HRT CATH W/VENTRCLGRPH(P
|
Professional
|
Both
|
$470.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
761P2476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$164.50 |
| Max. Negotiated Rate |
$1,456.69 |
| Rate for Payer: Aetna Commercial |
$1,330.14
|
| Rate for Payer: Anthem Medicaid |
$740.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$470.00
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cash Price |
$235.00
|
| Rate for Payer: Cigna Commercial |
$1,456.69
|
| Rate for Payer: Healthspan PPO |
$988.48
|
| Rate for Payer: Humana Medicaid |
$740.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$354.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$755.08
|
| Rate for Payer: Molina Healthcare Passport |
$740.27
|
| Rate for Payer: Multiplan PHCS |
$282.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$329.00
|
| Rate for Payer: UHCCP Medicaid |
$164.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$747.67
|
|
|
LEFT HRT CATH W/VENTRCLGRPH(T
|
Facility
|
OP
|
$10,902.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
761T2476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,417.26 |
| Max. Negotiated Rate |
$10,465.92 |
| Rate for Payer: Aetna Commercial |
$8,394.54
|
| Rate for Payer: Anthem Medicaid |
$3,749.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,817.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,503.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,944.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,804.10
|
| Rate for Payer: Cash Price |
$5,451.00
|
| Rate for Payer: Cash Price |
$5,451.00
|
| Rate for Payer: Cigna Commercial |
$9,048.66
|
| Rate for Payer: First Health Commercial |
$10,356.90
|
| Rate for Payer: Humana Commercial |
$9,266.70
|
| Rate for Payer: Humana KY Medicaid |
$3,749.20
|
| Rate for Payer: Humana Medicare Advantage |
$2,817.85
|
| Rate for Payer: Kentucky WC Medicaid |
$3,787.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,939.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,045.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,381.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,824.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,593.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,176.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,379.62
|
| Rate for Payer: PHCS Commercial |
$10,465.92
|
| Rate for Payer: United Healthcare All Payer |
$9,593.76
|
|
|
LEFT HRT CATH W/VENTRCLGRPH(T
|
Facility
|
IP
|
$10,902.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
761T2476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,417.26 |
| Max. Negotiated Rate |
$10,465.92 |
| Rate for Payer: Aetna Commercial |
$8,394.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,503.56
|
| Rate for Payer: Cash Price |
$5,451.00
|
| Rate for Payer: Cigna Commercial |
$9,048.66
|
| Rate for Payer: First Health Commercial |
$10,356.90
|
| Rate for Payer: Humana Commercial |
$9,266.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,939.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,045.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,270.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,593.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,176.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,379.62
|
| Rate for Payer: PHCS Commercial |
$10,465.92
|
| Rate for Payer: United Healthcare All Payer |
$9,593.76
|
|
|
LEFT HRT CATH W/VENTRCLGRPHY
|
Facility
|
OP
|
$10,902.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
48100063
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,417.26 |
| Max. Negotiated Rate |
$10,465.92 |
| Rate for Payer: Aetna Commercial |
$8,394.54
|
| Rate for Payer: Anthem Medicaid |
$3,749.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,817.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,503.56
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,944.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,804.10
|
| Rate for Payer: Cash Price |
$5,451.00
|
| Rate for Payer: Cash Price |
$5,451.00
|
| Rate for Payer: Cigna Commercial |
$9,048.66
|
| Rate for Payer: First Health Commercial |
$10,356.90
|
| Rate for Payer: Humana Commercial |
$9,266.70
|
| Rate for Payer: Humana KY Medicaid |
$3,749.20
|
| Rate for Payer: Humana Medicare Advantage |
$2,817.85
|
| Rate for Payer: Kentucky WC Medicaid |
$3,787.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,939.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,045.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,381.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,824.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,593.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,176.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,379.62
|
| Rate for Payer: PHCS Commercial |
$10,465.92
|
| Rate for Payer: United Healthcare All Payer |
$9,593.76
|
|
|
LEFT HRT CATH W/VENTRCLGRPHY
|
Professional
|
Both
|
$11,372.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
76102476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$354.69 |
| Max. Negotiated Rate |
$11,372.00 |
| Rate for Payer: Aetna Commercial |
$1,330.14
|
| Rate for Payer: Anthem Medicaid |
$740.27
|
| Rate for Payer: Buckeye Medicare Advantage |
$11,372.00
|
| Rate for Payer: Cash Price |
$5,686.00
|
| Rate for Payer: Cash Price |
$5,686.00
|
| Rate for Payer: Cigna Commercial |
$1,456.69
|
| Rate for Payer: Healthspan PPO |
$988.48
|
| Rate for Payer: Humana Medicaid |
$740.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$354.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$755.08
|
| Rate for Payer: Molina Healthcare Passport |
$740.27
|
| Rate for Payer: Multiplan PHCS |
$6,823.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$7,960.40
|
| Rate for Payer: UHCCP Medicaid |
$3,980.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$747.67
|
|
|
LEFT HRT CATH W/VENTRCLGRPHY
|
Facility
|
OP
|
$11,372.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
76102476
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,478.36 |
| Max. Negotiated Rate |
$10,917.12 |
| Rate for Payer: Aetna Commercial |
$8,756.44
|
| Rate for Payer: Anthem Medicaid |
$3,910.83
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,817.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,870.16
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,944.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,804.10
|
| Rate for Payer: Cash Price |
$5,686.00
|
| Rate for Payer: Cash Price |
$5,686.00
|
| Rate for Payer: Cigna Commercial |
$9,438.76
|
| Rate for Payer: First Health Commercial |
$10,803.40
|
| Rate for Payer: Humana Commercial |
$9,666.20
|
| Rate for Payer: Humana KY Medicaid |
$3,910.83
|
| Rate for Payer: Humana Medicare Advantage |
$2,817.85
|
| Rate for Payer: Kentucky WC Medicaid |
$3,950.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,325.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,392.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,381.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,989.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,007.36
|
| Rate for Payer: Ohio Health Group HMO |
$8,529.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,274.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,478.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,525.32
|
| Rate for Payer: PHCS Commercial |
$10,917.12
|
| Rate for Payer: United Healthcare All Payer |
$10,007.36
|
|
|
LEFT HRT CATH W/VENTRCLGRPHY
|
Facility
|
IP
|
$10,902.00
|
|
|
Service Code
|
HCPCS 93452
|
| Hospital Charge Code |
48100063
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,417.26 |
| Max. Negotiated Rate |
$10,465.92 |
| Rate for Payer: Aetna Commercial |
$8,394.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,503.56
|
| Rate for Payer: Cash Price |
$5,451.00
|
| Rate for Payer: Cigna Commercial |
$9,048.66
|
| Rate for Payer: First Health Commercial |
$10,356.90
|
| Rate for Payer: Humana Commercial |
$9,266.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,939.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,045.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,270.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,593.76
|
| Rate for Payer: Ohio Health Group HMO |
$8,176.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,180.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,379.62
|
| Rate for Payer: PHCS Commercial |
$10,465.92
|
| Rate for Payer: United Healthcare All Payer |
$9,593.76
|
|
