|
LIDODERM (LIDOCAINE) PATCH 5EA
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 591352530
|
| Hospital Charge Code |
25000874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
LIDODERM (LIDOCAINE) PATCH 5EA
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 591352530
|
| Hospital Charge Code |
25000874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.41
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
LIDO+EPI 0.5%-1:200K 50ML MDV
|
Facility
|
OP
|
$79.86
|
|
|
Service Code
|
NDC 409317716
|
| Hospital Charge Code |
25004232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$76.67 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: Anthem Medicaid |
$27.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.29
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna Commercial |
$66.28
|
| Rate for Payer: First Health Commercial |
$75.87
|
| Rate for Payer: Humana Commercial |
$67.88
|
| Rate for Payer: Humana KY Medicaid |
$27.46
|
| Rate for Payer: Kentucky WC Medicaid |
$27.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.28
|
| Rate for Payer: Ohio Health Group HMO |
$59.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.76
|
| Rate for Payer: PHCS Commercial |
$76.67
|
| Rate for Payer: United Healthcare All Payer |
$70.28
|
|
|
LIDO+EPI 0.5%-1:200K 50ML MDV
|
Facility
|
IP
|
$79.86
|
|
|
Service Code
|
NDC 409317716
|
| Hospital Charge Code |
25004232
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$76.67 |
| Rate for Payer: Aetna Commercial |
$61.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.29
|
| Rate for Payer: Cash Price |
$39.93
|
| Rate for Payer: Cigna Commercial |
$66.28
|
| Rate for Payer: First Health Commercial |
$75.87
|
| Rate for Payer: Humana Commercial |
$67.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.28
|
| Rate for Payer: Ohio Health Group HMO |
$59.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.76
|
| Rate for Payer: PHCS Commercial |
$76.67
|
| Rate for Payer: United Healthcare All Payer |
$70.28
|
|
|
LIDO+EPI 1%-1:100K MDV 30 VIAL
|
Facility
|
OP
|
$112.67
|
|
|
Service Code
|
NDC 409317817
|
| Hospital Charge Code |
25003959
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna Commercial |
$86.76
|
| Rate for Payer: Anthem Medicaid |
$38.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.88
|
| Rate for Payer: Cash Price |
$56.34
|
| Rate for Payer: Cigna Commercial |
$93.52
|
| Rate for Payer: First Health Commercial |
$107.04
|
| Rate for Payer: Humana Commercial |
$95.77
|
| Rate for Payer: Humana KY Medicaid |
$38.75
|
| Rate for Payer: Kentucky WC Medicaid |
$39.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.15
|
| Rate for Payer: Ohio Health Group HMO |
$84.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.93
|
| Rate for Payer: PHCS Commercial |
$108.16
|
| Rate for Payer: United Healthcare All Payer |
$99.15
|
|
|
LIDO+EPI 1%-1:100K MDV 30 VIAL
|
Facility
|
IP
|
$112.67
|
|
|
Service Code
|
NDC 409317817
|
| Hospital Charge Code |
25003959
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$108.16 |
| Rate for Payer: Aetna Commercial |
$86.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.88
|
| Rate for Payer: Cash Price |
$56.34
|
| Rate for Payer: Cigna Commercial |
$93.52
|
| Rate for Payer: First Health Commercial |
$107.04
|
| Rate for Payer: Humana Commercial |
$95.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.15
|
| Rate for Payer: Ohio Health Group HMO |
$84.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.93
|
| Rate for Payer: PHCS Commercial |
$108.16
|
| Rate for Payer: United Healthcare All Payer |
$99.15
|
|
|
LIDO+EPI 2%-1:100K MDV 30ML VL
|
Facility
|
IP
|
$80.39
|
|
|
Service Code
|
NDC 63323048301
|
| Hospital Charge Code |
25004024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.70
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.72
|
| Rate for Payer: First Health Commercial |
$76.37
|
| Rate for Payer: Humana Commercial |
$68.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.74
|
| Rate for Payer: Ohio Health Group HMO |
$60.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.92
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
LIDO+EPI 2%-1:100K MDV 30ML VL
|
Facility
|
OP
|
$80.39
|
|
|
Service Code
|
NDC 63323048301
|
| Hospital Charge Code |
25004024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$77.17 |
| Rate for Payer: Aetna Commercial |
$61.90
|
| Rate for Payer: Anthem Medicaid |
$27.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62.70
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cigna Commercial |
$66.72
|
| Rate for Payer: First Health Commercial |
$76.37
|
| Rate for Payer: Humana Commercial |
$68.33
|
| Rate for Payer: Humana KY Medicaid |
$27.65
|
| Rate for Payer: Kentucky WC Medicaid |
$27.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$59.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$28.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$70.74
|
| Rate for Payer: Ohio Health Group HMO |
$60.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24.92
|
| Rate for Payer: PHCS Commercial |
$77.17
|
| Rate for Payer: United Healthcare All Payer |
$70.74
|
|
|
LIFESTREAM COV STENT 10*38*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV STENT 10*38*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV STENT 10*58*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV STENT 10*58*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV STENT 12*38*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV STENT 12*38*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 5*26*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 5*26*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 5*37*135
|
Facility
|
OP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem Medicaid |
$3,896.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Humana KY Medicaid |
$3,896.39
|
| Rate for Payer: Kentucky WC Medicaid |
$3,936.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,974.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 5*37*135
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
|
LIFESTREAM COV. STENT 6*16*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 6*16*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 6*26*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 6*26*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 6*37*135
|
Facility
|
IP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 6*37*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
|
LIFESTREAM COV. STENT 6*58*135
|
Facility
|
OP
|
$17,700.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,301.00 |
| Max. Negotiated Rate |
$16,992.00 |
| Rate for Payer: Aetna Commercial |
$13,629.00
|
| Rate for Payer: Anthem Medicaid |
$6,087.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,806.00
|
| Rate for Payer: Cash Price |
$8,850.00
|
| Rate for Payer: Cigna Commercial |
$14,691.00
|
| Rate for Payer: First Health Commercial |
$16,815.00
|
| Rate for Payer: Humana Commercial |
$15,045.00
|
| Rate for Payer: Humana KY Medicaid |
$6,087.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,148.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,514.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,062.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,310.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,209.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,576.00
|
| Rate for Payer: Ohio Health Group HMO |
$13,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,301.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,487.00
|
| Rate for Payer: PHCS Commercial |
$16,992.00
|
| Rate for Payer: United Healthcare All Payer |
$15,576.00
|
|
