|
NIPPLE/AREOLA RECONSTRUCTION
|
Facility
|
OP
|
$4,614.69
|
|
|
Service Code
|
CPT 19350
|
| Hospital Charge Code |
76100313
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,296.21 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
|
|
NIPPLE/AREOLA RECONSTRUCTION
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 19350
|
| Hospital Charge Code |
76100313
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
NIPPLE/AREOLA RECONSTRUCTION
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 19350
|
| Hospital Charge Code |
76100313
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$457.13 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$983.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$457.13
|
| Rate for Payer: Anthem Medicaid |
$464.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$947.40
|
| Rate for Payer: Healthspan PPO |
$959.97
|
| Rate for Payer: Humana Medicaid |
$464.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$865.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.63
|
| Rate for Payer: Molina Healthcare Passport |
$464.34
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$479.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.98
|
|
|
NIPPLE/AREOLA RECONSTRUCTION
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 19350
|
| Hospital Charge Code |
76100313
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
NIPPLE/AREOLA RECONSTRUCTION
|
Facility
|
OP
|
$4,614.69
|
|
|
Service Code
|
CPT 19350
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,296.21 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
|
|
NIPPLE/AREOLA RECONSTRUCTION(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 19350
|
| Hospital Charge Code |
761P0313
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$457.13 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$983.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$457.13
|
| Rate for Payer: Anthem Medicaid |
$464.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$947.40
|
| Rate for Payer: Healthspan PPO |
$959.97
|
| Rate for Payer: Humana Medicaid |
$464.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$865.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.63
|
| Rate for Payer: Molina Healthcare Passport |
$464.34
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$479.99
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.98
|
|
|
NIPPLE EXPLORATION EXC
|
Professional
|
Both
|
$6,918.00
|
|
|
Service Code
|
HCPCS 19110
|
| Hospital Charge Code |
76100286
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.69 |
| Max. Negotiated Rate |
$6,918.00 |
| Rate for Payer: Aetna Commercial |
$461.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$181.69
|
| Rate for Payer: Anthem Medicaid |
$200.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,918.00
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cigna Commercial |
$426.37
|
| Rate for Payer: Healthspan PPO |
$498.57
|
| Rate for Payer: Humana Medicaid |
$200.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$420.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$204.15
|
| Rate for Payer: Molina Healthcare Passport |
$200.15
|
| Rate for Payer: Multiplan PHCS |
$4,150.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,842.60
|
| Rate for Payer: UHCCP Medicaid |
$190.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$202.15
|
|
|
NIPPLE EXPLORATION EXC
|
Facility
|
OP
|
$6,918.00
|
|
|
Service Code
|
HCPCS 19110
|
| Hospital Charge Code |
76100286
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$899.34 |
| Max. Negotiated Rate |
$6,641.28 |
| Rate for Payer: Aetna Commercial |
$5,326.86
|
| Rate for Payer: Anthem Medicaid |
$2,379.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,396.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cigna Commercial |
$5,741.94
|
| Rate for Payer: First Health Commercial |
$6,572.10
|
| Rate for Payer: Humana Commercial |
$5,880.30
|
| Rate for Payer: Humana KY Medicaid |
$2,379.10
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,403.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,672.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,105.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,426.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,087.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,188.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,383.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$899.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,144.58
|
| Rate for Payer: PHCS Commercial |
$6,641.28
|
| Rate for Payer: United Healthcare All Payer |
$6,087.84
|
|
|
NIPPLE EXPLORATION EXC
|
Facility
|
IP
|
$6,918.00
|
|
|
Service Code
|
HCPCS 19110
|
| Hospital Charge Code |
76100286
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$899.34 |
| Max. Negotiated Rate |
$6,641.28 |
| Rate for Payer: Aetna Commercial |
$5,326.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,396.04
|
| Rate for Payer: Cash Price |
$3,459.00
|
| Rate for Payer: Cigna Commercial |
$5,741.94
|
| Rate for Payer: First Health Commercial |
$6,572.10
|
| Rate for Payer: Humana Commercial |
$5,880.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,672.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,105.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,075.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,087.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,188.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,383.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$899.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,144.58
|
| Rate for Payer: PHCS Commercial |
$6,641.28
|
| Rate for Payer: United Healthcare All Payer |
$6,087.84
|
|
|
NIPPLE EXPLORATION EXC(P
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 19110
|
| Hospital Charge Code |
761P0286
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.69 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$461.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$181.69
|
| Rate for Payer: Anthem Medicaid |
$200.15
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$426.37
|
| Rate for Payer: Healthspan PPO |
$498.57
|
| Rate for Payer: Humana Medicaid |
$200.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$420.49
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$204.15
|
| Rate for Payer: Molina Healthcare Passport |
$200.15
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$190.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$202.15
|
|
|
NIPPLE EXPLORATION EXC(T
|
Facility
|
OP
|
$6,218.00
|
|
|
Service Code
|
HCPCS 19110
|
| Hospital Charge Code |
761T0286
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$808.34 |
| Max. Negotiated Rate |
$5,969.28 |
| Rate for Payer: Aetna Commercial |
$4,787.86
|
| Rate for Payer: Anthem Medicaid |
$2,138.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,850.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$3,109.00
|
| Rate for Payer: Cash Price |
$3,109.00
|
| Rate for Payer: Cigna Commercial |
$5,160.94
|
| Rate for Payer: First Health Commercial |
$5,907.10
|
| Rate for Payer: Humana Commercial |
$5,285.30
|
| Rate for Payer: Humana KY Medicaid |
$2,138.37
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,160.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,098.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,588.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,181.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,471.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,663.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,243.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$808.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,927.58
|
| Rate for Payer: PHCS Commercial |
$5,969.28
|
| Rate for Payer: United Healthcare All Payer |
$5,471.84
|
|
|
NIPPLE EXPLORATION EXC(T
|
Facility
|
IP
|
$6,218.00
|
|
|
Service Code
|
HCPCS 19110
|
| Hospital Charge Code |
761T0286
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$808.34 |
| Max. Negotiated Rate |
$5,969.28 |
| Rate for Payer: Aetna Commercial |
$4,787.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,850.04
|
| Rate for Payer: Cash Price |
$3,109.00
|
| Rate for Payer: Cigna Commercial |
$5,160.94
|
| Rate for Payer: First Health Commercial |
$5,907.10
|
| Rate for Payer: Humana Commercial |
$5,285.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,098.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,588.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,865.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,471.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,663.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,243.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$808.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,927.58
|
| Rate for Payer: PHCS Commercial |
$5,969.28
|
| Rate for Payer: United Healthcare All Payer |
$5,471.84
|
|
|
NIPRIDE KIT FOR CARD
|
Facility
|
IP
|
$558.00
|
|
|
Service Code
|
NDC 25021031002
|
| Hospital Charge Code |
25003273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.54 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna Commercial |
$429.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.24
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$463.14
|
| Rate for Payer: First Health Commercial |
$530.10
|
| Rate for Payer: Humana Commercial |
$474.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$457.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$411.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.04
|
| Rate for Payer: Ohio Health Group HMO |
$418.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$111.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.98
|
| Rate for Payer: PHCS Commercial |
$535.68
|
| Rate for Payer: United Healthcare All Payer |
$491.04
|
|
|
NIPRIDE KIT FOR CARD
|
Facility
|
OP
|
$558.00
|
|
|
Service Code
|
NDC 25021031002
|
| Hospital Charge Code |
25003273
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$72.54 |
| Max. Negotiated Rate |
$535.68 |
| Rate for Payer: Aetna Commercial |
$429.66
|
| Rate for Payer: Anthem Medicaid |
$191.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$435.24
|
| Rate for Payer: Cash Price |
$279.00
|
| Rate for Payer: Cigna Commercial |
$463.14
|
| Rate for Payer: First Health Commercial |
$530.10
|
| Rate for Payer: Humana Commercial |
$474.30
|
| Rate for Payer: Humana KY Medicaid |
$191.90
|
| Rate for Payer: Kentucky WC Medicaid |
$193.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$457.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$411.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$195.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.04
|
| Rate for Payer: Ohio Health Group HMO |
$418.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$111.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$72.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$172.98
|
| Rate for Payer: PHCS Commercial |
$535.68
|
| Rate for Payer: United Healthcare All Payer |
$491.04
|
|
|
NIPRIDE (SOD NITROPRU 50MG/2ML
|
Facility
|
OP
|
$186.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem Medicaid |
$63.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Humana KY Medicaid |
$63.97
|
| Rate for Payer: Kentucky WC Medicaid |
$64.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
NIPRIDE (SOD NITROPRU 50MG/2ML
|
Facility
|
IP
|
$186.00
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25003272
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.18 |
| Max. Negotiated Rate |
$178.56 |
| Rate for Payer: Aetna Commercial |
$143.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.08
|
| Rate for Payer: Cash Price |
$93.00
|
| Rate for Payer: Cigna Commercial |
$154.38
|
| Rate for Payer: First Health Commercial |
$176.70
|
| Rate for Payer: Humana Commercial |
$158.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$163.68
|
| Rate for Payer: Ohio Health Group HMO |
$139.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.66
|
| Rate for Payer: PHCS Commercial |
$178.56
|
| Rate for Payer: United Healthcare All Payer |
$163.68
|
|
|
NIRXCELL STENT 2.5*12
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*12
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*17
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*17
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*20
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*20
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*8
|
Facility
|
IP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.5*8
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
|
NIRXCELL STENT 2.75*12
|
Facility
|
OP
|
$3,775.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$490.75 |
| Max. Negotiated Rate |
$3,624.00 |
| Rate for Payer: Aetna Commercial |
$2,906.75
|
| Rate for Payer: Anthem Medicaid |
$1,298.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,944.50
|
| Rate for Payer: Cash Price |
$1,887.50
|
| Rate for Payer: Cigna Commercial |
$3,133.25
|
| Rate for Payer: First Health Commercial |
$3,586.25
|
| Rate for Payer: Humana Commercial |
$3,208.75
|
| Rate for Payer: Humana KY Medicaid |
$1,298.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,311.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,095.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,785.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,132.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,324.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,322.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,831.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$755.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$490.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,170.25
|
| Rate for Payer: PHCS Commercial |
$3,624.00
|
| Rate for Payer: United Healthcare All Payer |
$3,322.00
|
|
