|
LEAD COMPACT 1*8 MRI 75CM
|
Facility
|
OP
|
$10,099.25
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,029.78 |
| Max. Negotiated Rate |
$9,695.28 |
| Rate for Payer: Aetna Commercial |
$7,776.42
|
| Rate for Payer: Anthem Medicaid |
$3,473.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,877.41
|
| Rate for Payer: Cash Price |
$5,049.62
|
| Rate for Payer: Cigna Commercial |
$8,382.38
|
| Rate for Payer: First Health Commercial |
$9,594.29
|
| Rate for Payer: Humana Commercial |
$8,584.36
|
| Rate for Payer: Humana KY Medicaid |
$3,473.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3,508.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,281.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,453.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,029.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,542.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,887.34
|
| Rate for Payer: Ohio Health Group HMO |
$7,574.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,079.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,786.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,968.48
|
| Rate for Payer: PHCS Commercial |
$9,695.28
|
| Rate for Payer: United Healthcare All Payer |
$8,887.34
|
|
|
LEAD COMPACT 1*8 MRI 75CM
|
Facility
|
IP
|
$10,099.25
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,029.78 |
| Max. Negotiated Rate |
$9,695.28 |
| Rate for Payer: Aetna Commercial |
$7,776.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,877.41
|
| Rate for Payer: Cash Price |
$5,049.62
|
| Rate for Payer: Cigna Commercial |
$8,382.38
|
| Rate for Payer: First Health Commercial |
$9,594.29
|
| Rate for Payer: Humana Commercial |
$8,584.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,281.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,453.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,029.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,887.34
|
| Rate for Payer: Ohio Health Group HMO |
$7,574.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,079.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,786.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,968.48
|
| Rate for Payer: PHCS Commercial |
$9,695.28
|
| Rate for Payer: United Healthcare All Payer |
$8,887.34
|
|
|
LEAD COMPACT 1*8 MRI 90CM
|
Facility
|
OP
|
$10,099.25
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,029.78 |
| Max. Negotiated Rate |
$9,695.28 |
| Rate for Payer: Aetna Commercial |
$7,776.42
|
| Rate for Payer: Anthem Medicaid |
$3,473.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,877.41
|
| Rate for Payer: Cash Price |
$5,049.62
|
| Rate for Payer: Cigna Commercial |
$8,382.38
|
| Rate for Payer: First Health Commercial |
$9,594.29
|
| Rate for Payer: Humana Commercial |
$8,584.36
|
| Rate for Payer: Humana KY Medicaid |
$3,473.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3,508.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,281.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,453.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,029.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,542.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,887.34
|
| Rate for Payer: Ohio Health Group HMO |
$7,574.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,079.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,786.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,968.48
|
| Rate for Payer: PHCS Commercial |
$9,695.28
|
| Rate for Payer: United Healthcare All Payer |
$8,887.34
|
|
|
LEAD COMPACT 1*8 MRI 90CM
|
Facility
|
IP
|
$10,099.25
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,029.78 |
| Max. Negotiated Rate |
$9,695.28 |
| Rate for Payer: Aetna Commercial |
$7,776.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,877.41
|
| Rate for Payer: Cash Price |
$5,049.62
|
| Rate for Payer: Cigna Commercial |
$8,382.38
|
| Rate for Payer: First Health Commercial |
$9,594.29
|
| Rate for Payer: Humana Commercial |
$8,584.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,281.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,453.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,029.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,887.34
|
| Rate for Payer: Ohio Health Group HMO |
$7,574.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,079.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,786.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,968.48
|
| Rate for Payer: PHCS Commercial |
$9,695.28
|
| Rate for Payer: United Healthcare All Payer |
$8,887.34
|
|
|
LEAD DEFIB OPTISURE 65CM LDA21
|
Facility
|
IP
|
$11,207.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000059
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
LEAD DEFIB OPTISURE 65CM LDA21
|
Facility
|
OP
|
$11,207.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000059
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,362.10 |
| Max. Negotiated Rate |
$10,758.72 |
| Rate for Payer: Aetna Commercial |
$8,629.39
|
| Rate for Payer: Anthem Medicaid |
$3,854.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,741.46
|
| Rate for Payer: Cash Price |
$5,603.50
|
| Rate for Payer: Cigna Commercial |
$9,301.81
|
| Rate for Payer: First Health Commercial |
$10,646.65
|
| Rate for Payer: Humana Commercial |
$9,525.95
|
| Rate for Payer: Humana KY Medicaid |
$3,854.09
|
| Rate for Payer: Kentucky WC Medicaid |
$3,893.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,189.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,270.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,362.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,931.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,862.16
|
| Rate for Payer: Ohio Health Group HMO |
$8,405.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,965.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,750.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,732.83
|
| Rate for Payer: PHCS Commercial |
$10,758.72
|
| Rate for Payer: United Healthcare All Payer |
$9,862.16
|
|
|
LEAD DEFIB RELIANCE AF 0158
|
Facility
|
IP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1899
|
| Hospital Charge Code |
27000067
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
LEAD DEFIB RELIANCE AF 0158
|
Facility
|
OP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1899
|
| Hospital Charge Code |
27000067
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem Medicaid |
$5,330.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Humana KY Medicaid |
$5,330.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,384.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,437.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
LEAD DEPLOYABLE 78CM 419578
|
Facility
|
IP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,761.50 |
| Max. Negotiated Rate |
$8,836.80 |
| Rate for Payer: Aetna Commercial |
$7,087.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,179.90
|
| Rate for Payer: Cash Price |
$4,602.50
|
| Rate for Payer: Cigna Commercial |
$7,640.15
|
| Rate for Payer: First Health Commercial |
$8,744.75
|
| Rate for Payer: Humana Commercial |
$7,824.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,548.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,793.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,761.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,100.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,903.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,008.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,351.45
|
| Rate for Payer: PHCS Commercial |
$8,836.80
|
| Rate for Payer: United Healthcare All Payer |
$8,100.40
|
|
|
LEAD DEPLOYABLE 78CM 419578
|
Facility
|
OP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,761.50 |
| Max. Negotiated Rate |
$8,836.80 |
| Rate for Payer: Aetna Commercial |
$7,087.85
|
| Rate for Payer: Anthem Medicaid |
$3,165.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,179.90
|
| Rate for Payer: Cash Price |
$4,602.50
|
| Rate for Payer: Cigna Commercial |
$7,640.15
|
| Rate for Payer: First Health Commercial |
$8,744.75
|
| Rate for Payer: Humana Commercial |
$7,824.25
|
| Rate for Payer: Humana KY Medicaid |
$3,165.60
|
| Rate for Payer: Kentucky WC Medicaid |
$3,197.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,548.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,793.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,761.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,229.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,100.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,903.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,008.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,351.45
|
| Rate for Payer: PHCS Commercial |
$8,836.80
|
| Rate for Payer: United Healthcare All Payer |
$8,100.40
|
|
|
LEAD DEPLOYABLE 88CM 419588
|
Facility
|
IP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,761.50 |
| Max. Negotiated Rate |
$8,836.80 |
| Rate for Payer: Aetna Commercial |
$7,087.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,179.90
|
| Rate for Payer: Cash Price |
$4,602.50
|
| Rate for Payer: Cigna Commercial |
$7,640.15
|
| Rate for Payer: First Health Commercial |
$8,744.75
|
| Rate for Payer: Humana Commercial |
$7,824.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,548.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,793.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,761.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,100.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,903.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,008.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,351.45
|
| Rate for Payer: PHCS Commercial |
$8,836.80
|
| Rate for Payer: United Healthcare All Payer |
$8,100.40
|
|
|
LEAD DEPLOYABLE 88CM 419588
|
Facility
|
OP
|
$9,205.00
|
|
|
Service Code
|
HCPCS C1898
|
| Hospital Charge Code |
27000066
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$2,761.50 |
| Max. Negotiated Rate |
$8,836.80 |
| Rate for Payer: Aetna Commercial |
$7,087.85
|
| Rate for Payer: Anthem Medicaid |
$3,165.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,179.90
|
| Rate for Payer: Cash Price |
$4,602.50
|
| Rate for Payer: Cigna Commercial |
$7,640.15
|
| Rate for Payer: First Health Commercial |
$8,744.75
|
| Rate for Payer: Humana Commercial |
$7,824.25
|
| Rate for Payer: Humana KY Medicaid |
$3,165.60
|
| Rate for Payer: Kentucky WC Medicaid |
$3,197.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,548.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,793.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,761.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,229.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,100.40
|
| Rate for Payer: Ohio Health Group HMO |
$6,903.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,364.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,008.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,351.45
|
| Rate for Payer: PHCS Commercial |
$8,836.80
|
| Rate for Payer: United Healthcare All Payer |
$8,100.40
|
|
|
LEAD DEXTRUS 4135
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,027.50 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem Medicaid |
$1,177.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Humana KY Medicaid |
$1,177.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,740.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,979.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,363.25
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
LEAD DEXTRUS 4135
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,027.50 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,740.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,979.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,363.25
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
LEAD DEXTRUS 4136
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
LEAD DEXTRUS 4136
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem Medicaid |
$1,590.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Humana KY Medicaid |
$1,590.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,606.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
LEAD DEXTRUS 4137
|
Facility
|
OP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem Medicaid |
$1,332.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Humana KY Medicaid |
$1,332.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,346.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,359.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
LEAD DEXTRUS 4137
|
Facility
|
IP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1779
|
| Hospital Charge Code |
27000061
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
LEAD DURATA 7120Q/65
|
Facility
|
IP
|
$16,980.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,094.00 |
| Max. Negotiated Rate |
$16,300.80 |
| Rate for Payer: Aetna Commercial |
$13,074.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,244.40
|
| Rate for Payer: Cash Price |
$8,490.00
|
| Rate for Payer: Cigna Commercial |
$14,093.40
|
| Rate for Payer: First Health Commercial |
$16,131.00
|
| Rate for Payer: Humana Commercial |
$14,433.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,923.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,531.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,094.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,942.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,735.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,772.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,716.20
|
| Rate for Payer: PHCS Commercial |
$16,300.80
|
| Rate for Payer: United Healthcare All Payer |
$14,942.40
|
|
|
LEAD DURATA 7120Q/65
|
Facility
|
OP
|
$16,980.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,094.00 |
| Max. Negotiated Rate |
$16,300.80 |
| Rate for Payer: Aetna Commercial |
$13,074.60
|
| Rate for Payer: Anthem Medicaid |
$5,839.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,244.40
|
| Rate for Payer: Cash Price |
$8,490.00
|
| Rate for Payer: Cigna Commercial |
$14,093.40
|
| Rate for Payer: First Health Commercial |
$16,131.00
|
| Rate for Payer: Humana Commercial |
$14,433.00
|
| Rate for Payer: Humana KY Medicaid |
$5,839.42
|
| Rate for Payer: Kentucky WC Medicaid |
$5,898.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,923.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,531.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,094.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,956.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,942.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,735.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,772.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,716.20
|
| Rate for Payer: PHCS Commercial |
$16,300.80
|
| Rate for Payer: United Healthcare All Payer |
$14,942.40
|
|
|
LEAD DURATA 7121/60
|
Facility
|
IP
|
$17,997.50
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,399.25 |
| Max. Negotiated Rate |
$17,277.60 |
| Rate for Payer: Aetna Commercial |
$13,858.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,038.05
|
| Rate for Payer: Cash Price |
$8,998.75
|
| Rate for Payer: Cigna Commercial |
$14,937.92
|
| Rate for Payer: First Health Commercial |
$17,097.62
|
| Rate for Payer: Humana Commercial |
$15,297.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,757.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,282.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,399.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,837.80
|
| Rate for Payer: Ohio Health Group HMO |
$13,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,398.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,657.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,418.27
|
| Rate for Payer: PHCS Commercial |
$17,277.60
|
| Rate for Payer: United Healthcare All Payer |
$15,837.80
|
|
|
LEAD DURATA 7121/60
|
Facility
|
OP
|
$17,997.50
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,399.25 |
| Max. Negotiated Rate |
$17,277.60 |
| Rate for Payer: Aetna Commercial |
$13,858.08
|
| Rate for Payer: Anthem Medicaid |
$6,189.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,038.05
|
| Rate for Payer: Cash Price |
$8,998.75
|
| Rate for Payer: Cigna Commercial |
$14,937.92
|
| Rate for Payer: First Health Commercial |
$17,097.62
|
| Rate for Payer: Humana Commercial |
$15,297.88
|
| Rate for Payer: Humana KY Medicaid |
$6,189.34
|
| Rate for Payer: Kentucky WC Medicaid |
$6,252.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,757.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,282.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,399.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,313.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,837.80
|
| Rate for Payer: Ohio Health Group HMO |
$13,498.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,398.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,657.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,418.27
|
| Rate for Payer: PHCS Commercial |
$17,277.60
|
| Rate for Payer: United Healthcare All Payer |
$15,837.80
|
|
|
LEAD DURATA 7121/65
|
Facility
|
IP
|
$16,240.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.00 |
| Max. Negotiated Rate |
$15,590.40 |
| Rate for Payer: Aetna Commercial |
$12,504.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,667.20
|
| Rate for Payer: Cash Price |
$8,120.00
|
| Rate for Payer: Cigna Commercial |
$13,479.20
|
| Rate for Payer: First Health Commercial |
$15,428.00
|
| Rate for Payer: Humana Commercial |
$13,804.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,316.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,985.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,872.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,291.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,128.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,205.60
|
| Rate for Payer: PHCS Commercial |
$15,590.40
|
| Rate for Payer: United Healthcare All Payer |
$14,291.20
|
|
|
LEAD DURATA 7121/65
|
Facility
|
OP
|
$16,240.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,872.00 |
| Max. Negotiated Rate |
$15,590.40 |
| Rate for Payer: Aetna Commercial |
$12,504.80
|
| Rate for Payer: Anthem Medicaid |
$5,584.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,667.20
|
| Rate for Payer: Cash Price |
$8,120.00
|
| Rate for Payer: Cigna Commercial |
$13,479.20
|
| Rate for Payer: First Health Commercial |
$15,428.00
|
| Rate for Payer: Humana Commercial |
$13,804.00
|
| Rate for Payer: Humana KY Medicaid |
$5,584.94
|
| Rate for Payer: Kentucky WC Medicaid |
$5,641.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,316.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,985.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,872.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,696.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,291.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,180.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,992.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,128.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,205.60
|
| Rate for Payer: PHCS Commercial |
$15,590.40
|
| Rate for Payer: United Healthcare All Payer |
$14,291.20
|
|
|
LEAD DURATA 7121Q/58
|
Facility
|
OP
|
$16,980.00
|
|
|
Service Code
|
HCPCS C1895
|
| Hospital Charge Code |
27000064
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,094.00 |
| Max. Negotiated Rate |
$16,300.80 |
| Rate for Payer: Aetna Commercial |
$13,074.60
|
| Rate for Payer: Anthem Medicaid |
$5,839.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,244.40
|
| Rate for Payer: Cash Price |
$8,490.00
|
| Rate for Payer: Cigna Commercial |
$14,093.40
|
| Rate for Payer: First Health Commercial |
$16,131.00
|
| Rate for Payer: Humana Commercial |
$14,433.00
|
| Rate for Payer: Humana KY Medicaid |
$5,839.42
|
| Rate for Payer: Kentucky WC Medicaid |
$5,898.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,923.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,531.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,094.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,956.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,942.40
|
| Rate for Payer: Ohio Health Group HMO |
$12,735.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,584.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,772.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,716.20
|
| Rate for Payer: PHCS Commercial |
$16,300.80
|
| Rate for Payer: United Healthcare All Payer |
$14,942.40
|
|
