|
MULTI LINK RX ULTRA STENT 5*13
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LINK RX ULTRA STENT 5*13
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LINK RX ULTRA STENT 5*18
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LINK RX ULTRA STENT 5*18
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LINK RX ULTRA STENT 5*28
|
Facility
|
IP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
MULTI LINK RX ULTRA STENT 5*28
|
Facility
|
OP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
MULTI LINK RX ULTRA STENT 5*38
|
Facility
|
OP
|
$4,531.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,359.38 |
| Max. Negotiated Rate |
$4,350.00 |
| Rate for Payer: Aetna Commercial |
$3,489.06
|
| Rate for Payer: Anthem Medicaid |
$1,558.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,534.38
|
| Rate for Payer: Cash Price |
$2,265.62
|
| Rate for Payer: Cigna Commercial |
$3,760.94
|
| Rate for Payer: First Health Commercial |
$4,304.69
|
| Rate for Payer: Humana Commercial |
$3,851.56
|
| Rate for Payer: Humana KY Medicaid |
$1,558.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,574.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,715.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,344.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,359.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,589.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,987.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,398.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,625.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,942.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,126.56
|
| Rate for Payer: PHCS Commercial |
$4,350.00
|
| Rate for Payer: United Healthcare All Payer |
$3,987.50
|
|
|
MULTI LINK RX ULTRA STENT 5*38
|
Facility
|
IP
|
$4,531.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,359.38 |
| Max. Negotiated Rate |
$4,350.00 |
| Rate for Payer: Aetna Commercial |
$3,489.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,534.38
|
| Rate for Payer: Cash Price |
$2,265.62
|
| Rate for Payer: Cigna Commercial |
$3,760.94
|
| Rate for Payer: First Health Commercial |
$4,304.69
|
| Rate for Payer: Humana Commercial |
$3,851.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,715.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,344.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,359.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,987.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,398.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,625.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,942.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,126.56
|
| Rate for Payer: PHCS Commercial |
$4,350.00
|
| Rate for Payer: United Healthcare All Payer |
$3,987.50
|
|
|
MULTI LNK RX ULTRA STNT 4.5*13
|
Facility
|
IP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
MULTI LNK RX ULTRA STNT 4.5*13
|
Facility
|
OP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| 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
|
|
|
MULTI LNK RX ULTRA STNT 4.5*18
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LNK RX ULTRA STNT 4.5*18
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LNK RX ULTRA STNT 4.5*28
|
Facility
|
OP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem Medicaid |
$1,526.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Humana KY Medicaid |
$1,526.06
|
| Rate for Payer: Kentucky WC Medicaid |
$1,541.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,556.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LNK RX ULTRA STNT 4.5*28
|
Facility
|
IP
|
$4,437.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$4,260.00 |
| Rate for Payer: Aetna Commercial |
$3,416.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,461.25
|
| Rate for Payer: Cash Price |
$2,218.75
|
| Rate for Payer: Cigna Commercial |
$3,683.12
|
| Rate for Payer: First Health Commercial |
$4,215.62
|
| Rate for Payer: Humana Commercial |
$3,771.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,638.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,274.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,331.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,905.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,328.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,550.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,860.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,061.88
|
| Rate for Payer: PHCS Commercial |
$4,260.00
|
| Rate for Payer: United Healthcare All Payer |
$3,905.00
|
|
|
MULTI LNK RX ULTRA STNT 4.5*38
|
Facility
|
OP
|
$4,531.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,359.38 |
| Max. Negotiated Rate |
$4,350.00 |
| Rate for Payer: Aetna Commercial |
$3,489.06
|
| Rate for Payer: Anthem Medicaid |
$1,558.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,534.38
|
| Rate for Payer: Cash Price |
$2,265.62
|
| Rate for Payer: Cigna Commercial |
$3,760.94
|
| Rate for Payer: First Health Commercial |
$4,304.69
|
| Rate for Payer: Humana Commercial |
$3,851.56
|
| Rate for Payer: Humana KY Medicaid |
$1,558.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,574.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,715.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,344.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,359.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,589.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,987.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,398.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,625.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,942.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,126.56
|
| Rate for Payer: PHCS Commercial |
$4,350.00
|
| Rate for Payer: United Healthcare All Payer |
$3,987.50
|
|
|
MULTI LNK RX ULTRA STNT 4.5*38
|
Facility
|
IP
|
$4,531.25
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,359.38 |
| Max. Negotiated Rate |
$4,350.00 |
| Rate for Payer: Aetna Commercial |
$3,489.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,534.38
|
| Rate for Payer: Cash Price |
$2,265.62
|
| Rate for Payer: Cigna Commercial |
$3,760.94
|
| Rate for Payer: First Health Commercial |
$4,304.69
|
| Rate for Payer: Humana Commercial |
$3,851.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,715.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,344.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,359.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,987.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,398.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,625.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,942.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,126.56
|
| Rate for Payer: PHCS Commercial |
$4,350.00
|
| Rate for Payer: United Healthcare All Payer |
$3,987.50
|
|
|
MULTI LUMEN 20CM 3 PORT
|
Facility
|
OP
|
$1,887.71
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.31 |
| Max. Negotiated Rate |
$1,812.20 |
| Rate for Payer: Aetna Commercial |
$1,453.54
|
| Rate for Payer: Anthem Medicaid |
$649.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,472.41
|
| Rate for Payer: Cash Price |
$943.85
|
| Rate for Payer: Cigna Commercial |
$1,566.80
|
| Rate for Payer: First Health Commercial |
$1,793.32
|
| Rate for Payer: Humana Commercial |
$1,604.55
|
| Rate for Payer: Humana KY Medicaid |
$649.18
|
| Rate for Payer: Kentucky WC Medicaid |
$655.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,547.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,393.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$662.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,661.18
|
| Rate for Payer: Ohio Health Group HMO |
$1,415.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,510.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,642.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,302.52
|
| Rate for Payer: PHCS Commercial |
$1,812.20
|
| Rate for Payer: United Healthcare All Payer |
$1,661.18
|
|
|
MULTI LUMEN 20CM 3 PORT
|
Facility
|
IP
|
$1,887.71
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$566.31 |
| Max. Negotiated Rate |
$1,812.20 |
| Rate for Payer: Aetna Commercial |
$1,453.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,472.41
|
| Rate for Payer: Cash Price |
$943.85
|
| Rate for Payer: Cigna Commercial |
$1,566.80
|
| Rate for Payer: First Health Commercial |
$1,793.32
|
| Rate for Payer: Humana Commercial |
$1,604.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,547.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,393.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,661.18
|
| Rate for Payer: Ohio Health Group HMO |
$1,415.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,510.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,642.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,302.52
|
| Rate for Payer: PHCS Commercial |
$1,812.20
|
| Rate for Payer: United Healthcare All Payer |
$1,661.18
|
|
|
MUMPS IGG
|
Facility
|
IP
|
$158.00
|
|
|
Service Code
|
HCPCS 86735
|
| Hospital Charge Code |
30001194
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$47.40 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna Commercial |
$121.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$126.87
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$131.14
|
| Rate for Payer: First Health Commercial |
$150.10
|
| Rate for Payer: Humana Commercial |
$134.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.04
|
| Rate for Payer: Ohio Health Group HMO |
$118.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.02
|
| Rate for Payer: PHCS Commercial |
$151.68
|
| Rate for Payer: United Healthcare All Payer |
$139.04
|
|
|
MUMPS IGG
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
HCPCS 86735
|
| Hospital Charge Code |
30001194
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$151.68 |
| Rate for Payer: Aetna Commercial |
$121.66
|
| Rate for Payer: Anthem Medicaid |
$13.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$13.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$126.87
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$18.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$13.05
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cash Price |
$79.00
|
| Rate for Payer: Cigna Commercial |
$131.14
|
| Rate for Payer: First Health Commercial |
$150.10
|
| Rate for Payer: Humana Commercial |
$134.30
|
| Rate for Payer: Humana KY Medicaid |
$13.05
|
| Rate for Payer: Humana Medicare Advantage |
$13.05
|
| Rate for Payer: Kentucky WC Medicaid |
$13.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.04
|
| Rate for Payer: Ohio Health Group HMO |
$118.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$126.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$109.02
|
| Rate for Payer: PHCS Commercial |
$151.68
|
| Rate for Payer: United Healthcare All Payer |
$139.04
|
|
|
MUPIROCIN 2% 1GM UD OINTMENT
|
Facility
|
OP
|
$11.57
|
|
|
Service Code
|
NDC 50268056815
|
| Hospital Charge Code |
25003240
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$11.11 |
| Rate for Payer: Aetna Commercial |
$8.91
|
| Rate for Payer: Anthem Medicaid |
$3.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.02
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: First Health Commercial |
$10.99
|
| Rate for Payer: Humana Commercial |
$9.83
|
| Rate for Payer: Humana KY Medicaid |
$3.98
|
| Rate for Payer: Kentucky WC Medicaid |
$4.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.18
|
| Rate for Payer: Ohio Health Group HMO |
$8.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.98
|
| Rate for Payer: PHCS Commercial |
$11.11
|
| Rate for Payer: United Healthcare All Payer |
$10.18
|
|
|
MUPIROCIN 2% 1GM UD OINTMENT
|
Facility
|
IP
|
$11.57
|
|
|
Service Code
|
NDC 50268056815
|
| Hospital Charge Code |
25003240
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.47 |
| Max. Negotiated Rate |
$11.11 |
| Rate for Payer: Aetna Commercial |
$8.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.02
|
| Rate for Payer: Cash Price |
$5.78
|
| Rate for Payer: Cigna Commercial |
$9.60
|
| Rate for Payer: First Health Commercial |
$10.99
|
| Rate for Payer: Humana Commercial |
$9.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.18
|
| Rate for Payer: Ohio Health Group HMO |
$8.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.98
|
| Rate for Payer: PHCS Commercial |
$11.11
|
| Rate for Payer: United Healthcare All Payer |
$10.18
|
|
|
MURO 128 5% DROPS 15ML
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 536125494
|
| Hospital Charge Code |
25003242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
|
MURO 128 5% DROPS 15ML
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 536125494
|
| Hospital Charge Code |
25003242
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.02
|
| Rate for Payer: Humana Commercial |
$0.02
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.02
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.02
|
| Rate for Payer: United Healthcare All Payer |
$0.02
|
|
|
MURO 128 EYE OINT 3.5 GM
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 536125391
|
| Hospital Charge Code |
25001019
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna Commercial |
$0.42
|
| Rate for Payer: Anthem Medicaid |
$0.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.42
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna Commercial |
$0.45
|
| Rate for Payer: First Health Commercial |
$0.51
|
| Rate for Payer: Humana Commercial |
$0.46
|
| Rate for Payer: Humana KY Medicaid |
$0.19
|
| Rate for Payer: Kentucky WC Medicaid |
$0.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.48
|
| Rate for Payer: Ohio Health Group HMO |
$0.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.37
|
| Rate for Payer: PHCS Commercial |
$0.52
|
| Rate for Payer: United Healthcare All Payer |
$0.48
|
|
