|
AUGMENT VNDR D FM 67.5X5 LL/RM
|
Facility
|
OP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem Medicaid |
$2,949.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Humana KY Medicaid |
$2,949.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,979.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,008.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT VNDR D FM 70X5 LL/RM
|
Facility
|
IP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT VNDR D FM 70X5 LL/RM
|
Facility
|
OP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem Medicaid |
$2,949.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Humana KY Medicaid |
$2,949.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,979.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,008.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT VNDR D FM 75X5 LL/RM
|
Facility
|
IP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT VNDR D FM 75X5 LL/RM
|
Facility
|
OP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem Medicaid |
$2,949.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Humana KY Medicaid |
$2,949.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,979.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,008.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT VNDR D FM 80X5 LL/RM
|
Facility
|
OP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem Medicaid |
$2,949.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Humana KY Medicaid |
$2,949.71
|
| Rate for Payer: Kentucky WC Medicaid |
$2,979.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,008.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT VNDR D FM 80X5 LL/RM
|
Facility
|
IP
|
$8,577.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.04 |
| Max. Negotiated Rate |
$8,234.13 |
| Rate for Payer: Aetna Commercial |
$6,604.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,690.23
|
| Rate for Payer: Cash Price |
$4,288.61
|
| Rate for Payer: Cigna Commercial |
$7,119.09
|
| Rate for Payer: First Health Commercial |
$8,148.36
|
| Rate for Payer: Humana Commercial |
$7,290.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,033.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,329.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,573.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,547.95
|
| Rate for Payer: Ohio Health Group HMO |
$6,432.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,715.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,658.94
|
| Rate for Payer: PHCS Commercial |
$8,234.13
|
| Rate for Payer: United Healthcare All Payer |
$7,547.95
|
|
|
AUGMENT XR(AMOX TR/KCLV)1000MG
|
Facility
|
IP
|
$23.70
|
|
|
Service Code
|
NDC 43598002028
|
| Hospital Charge Code |
25002858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$18.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.49
|
| Rate for Payer: Cash Price |
$11.85
|
| Rate for Payer: Cigna Commercial |
$19.67
|
| Rate for Payer: First Health Commercial |
$22.52
|
| Rate for Payer: Humana Commercial |
$20.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.86
|
| Rate for Payer: Ohio Health Group HMO |
$17.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.35
|
| Rate for Payer: PHCS Commercial |
$22.75
|
| Rate for Payer: United Healthcare All Payer |
$20.86
|
|
|
AUGMENT XR(AMOX TR/KCLV)1000MG
|
Facility
|
OP
|
$23.70
|
|
|
Service Code
|
NDC 43598002028
|
| Hospital Charge Code |
25002858
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.08 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$18.25
|
| Rate for Payer: Anthem Medicaid |
$8.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.49
|
| Rate for Payer: Cash Price |
$11.85
|
| Rate for Payer: Cigna Commercial |
$19.67
|
| Rate for Payer: First Health Commercial |
$22.52
|
| Rate for Payer: Humana Commercial |
$20.14
|
| Rate for Payer: Humana KY Medicaid |
$8.15
|
| Rate for Payer: Kentucky WC Medicaid |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.86
|
| Rate for Payer: Ohio Health Group HMO |
$17.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.35
|
| Rate for Payer: PHCS Commercial |
$22.75
|
| Rate for Payer: United Healthcare All Payer |
$20.86
|
|
|
AUTGRFT IMPLNT KNEE W/SCOPE
|
Facility
|
OP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 29866
|
| Hospital Charge Code |
76101092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.15 |
| Max. Negotiated Rate |
$8,661.10 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem Medicaid |
$431.59
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,186.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8,661.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,351.78
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Humana KY Medicaid |
$431.59
|
| Rate for Payer: Humana Medicare Advantage |
$6,186.50
|
| Rate for Payer: Kentucky WC Medicaid |
$435.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,423.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$440.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$251.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.05
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
AUTGRFT IMPLNT KNEE W/SCOPE
|
Facility
|
IP
|
$1,255.00
|
|
|
Service Code
|
HCPCS 29866
|
| Hospital Charge Code |
76101092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$163.15 |
| Max. Negotiated Rate |
$1,204.80 |
| Rate for Payer: Aetna Commercial |
$966.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$978.90
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,041.65
|
| Rate for Payer: First Health Commercial |
$1,192.25
|
| Rate for Payer: Humana Commercial |
$1,066.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,029.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$926.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$376.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,104.40
|
| Rate for Payer: Ohio Health Group HMO |
$941.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$251.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$163.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.05
|
| Rate for Payer: PHCS Commercial |
$1,204.80
|
| Rate for Payer: United Healthcare All Payer |
$1,104.40
|
|
|
AUTGRFT IMPLNT KNEE W/SCOPE
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 29866
|
| Hospital Charge Code |
76101092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$1,702.81 |
| Rate for Payer: Aetna Commercial |
$1,547.30
|
| Rate for Payer: Anthem Medicaid |
$763.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,255.00
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,702.81
|
| Rate for Payer: Healthspan PPO |
$1,401.53
|
| Rate for Payer: Humana Medicaid |
$763.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,306.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$778.34
|
| Rate for Payer: Molina Healthcare Passport |
$763.08
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$878.50
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$770.71
|
|
|
AUTGRFT IMPLNT KNEE W/SCOPE(P
|
Professional
|
Both
|
$1,255.00
|
|
|
Service Code
|
HCPCS 29866
|
| Hospital Charge Code |
761P1092
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$439.25 |
| Max. Negotiated Rate |
$1,702.81 |
| Rate for Payer: Aetna Commercial |
$1,547.30
|
| Rate for Payer: Anthem Medicaid |
$763.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,255.00
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cash Price |
$627.50
|
| Rate for Payer: Cigna Commercial |
$1,702.81
|
| Rate for Payer: Healthspan PPO |
$1,401.53
|
| Rate for Payer: Humana Medicaid |
$763.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,306.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$778.34
|
| Rate for Payer: Molina Healthcare Passport |
$763.08
|
| Rate for Payer: Multiplan PHCS |
$753.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$878.50
|
| Rate for Payer: UHCCP Medicaid |
$439.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$770.71
|
|
|
AUTOINJECTOR TV-AI01-E
|
Facility
|
IP
|
$3,946.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.04 |
| Max. Negotiated Rate |
$3,788.64 |
| Rate for Payer: Aetna Commercial |
$3,038.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,078.27
|
| Rate for Payer: Cash Price |
$1,973.25
|
| Rate for Payer: Cigna Commercial |
$3,275.60
|
| Rate for Payer: First Health Commercial |
$3,749.18
|
| Rate for Payer: Humana Commercial |
$3,354.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,236.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,912.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,183.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,472.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,959.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,223.42
|
| Rate for Payer: PHCS Commercial |
$3,788.64
|
| Rate for Payer: United Healthcare All Payer |
$3,472.92
|
|
|
AUTOINJECTOR TV-AI01-E
|
Facility
|
OP
|
$3,946.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.04 |
| Max. Negotiated Rate |
$3,788.64 |
| Rate for Payer: Aetna Commercial |
$3,038.80
|
| Rate for Payer: Anthem Medicaid |
$1,357.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,078.27
|
| Rate for Payer: Cash Price |
$1,973.25
|
| Rate for Payer: Cigna Commercial |
$3,275.60
|
| Rate for Payer: First Health Commercial |
$3,749.18
|
| Rate for Payer: Humana Commercial |
$3,354.52
|
| Rate for Payer: Humana KY Medicaid |
$1,357.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,371.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,236.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,912.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,183.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,384.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,472.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,959.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,223.42
|
| Rate for Payer: PHCS Commercial |
$3,788.64
|
| Rate for Payer: United Healthcare All Payer |
$3,472.92
|
|
|
AUTOINJECTOR TV-AI01-N
|
Facility
|
IP
|
$3,946.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.04 |
| Max. Negotiated Rate |
$3,788.64 |
| Rate for Payer: Aetna Commercial |
$3,038.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,078.27
|
| Rate for Payer: Cash Price |
$1,973.25
|
| Rate for Payer: Cigna Commercial |
$3,275.60
|
| Rate for Payer: First Health Commercial |
$3,749.18
|
| Rate for Payer: Humana Commercial |
$3,354.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,236.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,912.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,183.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,472.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,959.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,223.42
|
| Rate for Payer: PHCS Commercial |
$3,788.64
|
| Rate for Payer: United Healthcare All Payer |
$3,472.92
|
|
|
AUTOINJECTOR TV-AI01-N
|
Facility
|
OP
|
$3,946.50
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.04 |
| Max. Negotiated Rate |
$3,788.64 |
| Rate for Payer: Aetna Commercial |
$3,038.80
|
| Rate for Payer: Anthem Medicaid |
$1,357.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,078.27
|
| Rate for Payer: Cash Price |
$1,973.25
|
| Rate for Payer: Cigna Commercial |
$3,275.60
|
| Rate for Payer: First Health Commercial |
$3,749.18
|
| Rate for Payer: Humana Commercial |
$3,354.52
|
| Rate for Payer: Humana KY Medicaid |
$1,357.20
|
| Rate for Payer: Kentucky WC Medicaid |
$1,371.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,236.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,912.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,183.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,384.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,472.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,959.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$789.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,223.42
|
| Rate for Payer: PHCS Commercial |
$3,788.64
|
| Rate for Payer: United Healthcare All Payer |
$3,472.92
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC
|
Facility
|
IP
|
$72,259.81
|
|
|
Service Code
|
MSDRG 016
|
| Min. Negotiated Rate |
$49,033.44 |
| Max. Negotiated Rate |
$72,259.81 |
| Rate for Payer: Anthem Medicaid |
$49,033.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$51,614.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$72,259.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$69,679.10
|
| Rate for Payer: Humana KY Medicaid |
$49,033.44
|
| Rate for Payer: Humana Medicare Advantage |
$51,614.15
|
| Rate for Payer: Kentucky WC Medicaid |
$49,523.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61,936.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$50,014.11
|
|
|
AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC
|
Facility
|
IP
|
$72,259.81
|
|
|
Service Code
|
MSDRG 017
|
| Min. Negotiated Rate |
$49,033.44 |
| Max. Negotiated Rate |
$72,259.81 |
| Rate for Payer: Anthem Medicaid |
$49,033.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$51,614.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$72,259.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$69,679.10
|
| Rate for Payer: Humana KY Medicaid |
$49,033.44
|
| Rate for Payer: Humana Medicare Advantage |
$51,614.15
|
| Rate for Payer: Kentucky WC Medicaid |
$49,523.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$61,936.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$50,014.11
|
|
|
AUTONOMIC NRV PARASYM INERVJ
|
Professional
|
Both
|
$625.00
|
|
|
Service Code
|
HCPCS 95921
|
| Hospital Charge Code |
51000038
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$625.00 |
| Rate for Payer: Aetna Commercial |
$112.43
|
| Rate for Payer: Anthem Medicaid |
$64.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$625.00
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$98.95
|
| Rate for Payer: Healthspan PPO |
$99.02
|
| Rate for Payer: Humana Medicaid |
$64.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.59
|
| Rate for Payer: Molina Healthcare Passport |
$64.30
|
| Rate for Payer: Multiplan PHCS |
$375.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$437.50
|
| Rate for Payer: UHCCP Medicaid |
$218.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.94
|
|
|
AUTONOMIC NRV PARASYM INERVJ
|
Facility
|
IP
|
$625.00
|
|
|
Service Code
|
HCPCS 95921
|
| Hospital Charge Code |
51000038
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.25 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$481.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$487.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$518.75
|
| Rate for Payer: First Health Commercial |
$593.75
|
| Rate for Payer: Humana Commercial |
$531.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$512.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$461.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$187.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$550.00
|
| Rate for Payer: Ohio Health Group HMO |
$468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.75
|
| Rate for Payer: PHCS Commercial |
$600.00
|
| Rate for Payer: United Healthcare All Payer |
$550.00
|
|
|
AUTONOMIC NRV PARASYM INERVJ
|
Facility
|
OP
|
$625.00
|
|
|
Service Code
|
HCPCS 95921
|
| Hospital Charge Code |
51000038
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$81.25 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna Commercial |
$481.25
|
| Rate for Payer: Anthem Medicaid |
$214.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$487.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cash Price |
$312.50
|
| Rate for Payer: Cigna Commercial |
$518.75
|
| Rate for Payer: First Health Commercial |
$593.75
|
| Rate for Payer: Humana Commercial |
$531.25
|
| Rate for Payer: Humana KY Medicaid |
$214.94
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$217.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$512.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$461.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$219.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$550.00
|
| Rate for Payer: Ohio Health Group HMO |
$468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$125.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$81.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$193.75
|
| Rate for Payer: PHCS Commercial |
$600.00
|
| Rate for Payer: United Healthcare All Payer |
$550.00
|
|
|
AUTONOMIC NRV PARASYM INERV(P
|
Professional
|
Both
|
$245.00
|
|
|
Service Code
|
HCPCS 95921
|
| Hospital Charge Code |
510P0038
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$53.32 |
| Max. Negotiated Rate |
$245.00 |
| Rate for Payer: Aetna Commercial |
$112.43
|
| Rate for Payer: Anthem Medicaid |
$64.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$245.00
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cash Price |
$122.50
|
| Rate for Payer: Cigna Commercial |
$98.95
|
| Rate for Payer: Healthspan PPO |
$99.02
|
| Rate for Payer: Humana Medicaid |
$64.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$53.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$65.59
|
| Rate for Payer: Molina Healthcare Passport |
$64.30
|
| Rate for Payer: Multiplan PHCS |
$147.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.50
|
| Rate for Payer: UHCCP Medicaid |
$85.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$64.94
|
|
|
AUTONOMIC NRV PARASYM INERV(T
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS 95921
|
| Hospital Charge Code |
510T0038
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.40 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$292.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.40
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cigna Commercial |
$315.40
|
| Rate for Payer: First Health Commercial |
$361.00
|
| Rate for Payer: Humana Commercial |
$323.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$114.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.40
|
| Rate for Payer: Ohio Health Group HMO |
$285.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$117.80
|
| Rate for Payer: PHCS Commercial |
$364.80
|
| Rate for Payer: United Healthcare All Payer |
$334.40
|
|
|
AUTONOMIC NRV PARASYM INERV(T
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS 95921
|
| Hospital Charge Code |
510T0038
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.40 |
| Max. Negotiated Rate |
$364.80 |
| Rate for Payer: Aetna Commercial |
$292.60
|
| Rate for Payer: Anthem Medicaid |
$130.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$135.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$296.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$189.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$182.36
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cigna Commercial |
$315.40
|
| Rate for Payer: First Health Commercial |
$361.00
|
| Rate for Payer: Humana Commercial |
$323.00
|
| Rate for Payer: Humana KY Medicaid |
$130.68
|
| Rate for Payer: Humana Medicare Advantage |
$135.08
|
| Rate for Payer: Kentucky WC Medicaid |
$132.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$311.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$280.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$133.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$334.40
|
| Rate for Payer: Ohio Health Group HMO |
$285.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$49.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$117.80
|
| Rate for Payer: PHCS Commercial |
$364.80
|
| Rate for Payer: United Healthcare All Payer |
$334.40
|
|
