|
PRGRMG DEV EVAL SCRMS IP
|
Facility
|
IP
|
$196.00
|
|
|
Service Code
|
HCPCS 93285
|
| Hospital Charge Code |
48000082
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$25.48 |
| Max. Negotiated Rate |
$188.16 |
| Rate for Payer: Aetna Commercial |
$150.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$152.88
|
| Rate for Payer: Cash Price |
$98.00
|
| Rate for Payer: Cigna Commercial |
$162.68
|
| Rate for Payer: First Health Commercial |
$186.20
|
| Rate for Payer: Humana Commercial |
$166.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$160.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$144.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$172.48
|
| Rate for Payer: Ohio Health Group HMO |
$147.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$39.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$60.76
|
| Rate for Payer: PHCS Commercial |
$188.16
|
| Rate for Payer: United Healthcare All Payer |
$172.48
|
|
|
PRGRMG EVAL IMPLANTABLE DFB
|
Facility
|
OP
|
$191.00
|
|
|
Service Code
|
HCPCS 93284
|
| Hospital Charge Code |
48000081
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$24.83 |
| Max. Negotiated Rate |
$183.36 |
| Rate for Payer: Aetna Commercial |
$147.07
|
| Rate for Payer: Anthem Medicaid |
$65.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$32.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$45.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$44.02
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$158.53
|
| Rate for Payer: First Health Commercial |
$181.45
|
| Rate for Payer: Humana Commercial |
$162.35
|
| Rate for Payer: Humana KY Medicaid |
$65.68
|
| Rate for Payer: Humana Medicare Advantage |
$32.61
|
| Rate for Payer: Kentucky WC Medicaid |
$66.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$39.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$67.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.08
|
| Rate for Payer: Ohio Health Group HMO |
$143.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.21
|
| Rate for Payer: PHCS Commercial |
$183.36
|
| Rate for Payer: United Healthcare All Payer |
$168.08
|
|
|
PRGRMG EVAL IMPLANTABLE DFB
|
Facility
|
IP
|
$191.00
|
|
|
Service Code
|
HCPCS 93284
|
| Hospital Charge Code |
48000081
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$24.83 |
| Max. Negotiated Rate |
$183.36 |
| Rate for Payer: Aetna Commercial |
$147.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$148.98
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$158.53
|
| Rate for Payer: First Health Commercial |
$181.45
|
| Rate for Payer: Humana Commercial |
$162.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$156.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$140.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$57.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$168.08
|
| Rate for Payer: Ohio Health Group HMO |
$143.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$38.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.21
|
| Rate for Payer: PHCS Commercial |
$183.36
|
| Rate for Payer: United Healthcare All Payer |
$168.08
|
|
|
PRGRMG EVAL IMPLANTABLE DFB
|
Professional
|
Both
|
$191.00
|
|
|
Service Code
|
HCPCS 93284
|
| Hospital Charge Code |
48000081
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$66.85 |
| Max. Negotiated Rate |
$191.00 |
| Rate for Payer: Aetna Commercial |
$165.49
|
| Rate for Payer: Anthem Medicaid |
$83.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$191.00
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cash Price |
$95.50
|
| Rate for Payer: Cigna Commercial |
$167.48
|
| Rate for Payer: Healthspan PPO |
$155.55
|
| Rate for Payer: Humana Medicaid |
$83.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$87.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.34
|
| Rate for Payer: Molina Healthcare Passport |
$83.67
|
| Rate for Payer: Multiplan PHCS |
$114.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$133.70
|
| Rate for Payer: UHCCP Medicaid |
$66.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.51
|
|
|
PRILOSEC (OMEPRAZOLE 10MG/1CAP
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 68462039501
|
| Hospital Charge Code |
25001229
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PRILOSEC (OMEPRAZOLE 10MG/1CAP
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 68462039501
|
| Hospital Charge Code |
25001229
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.35
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
PRILOSEC (OMEPRAZOLE 20MG/1CAP
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 68084012801
|
| Hospital Charge Code |
25001230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
PRILOSEC (OMEPRAZOLE 20MG/1CAP
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 68084012801
|
| Hospital Charge Code |
25001230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$4.40 |
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Anthem Medicaid |
$1.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.57
|
| Rate for Payer: Cash Price |
$2.29
|
| Rate for Payer: Cigna Commercial |
$3.80
|
| Rate for Payer: First Health Commercial |
$4.35
|
| Rate for Payer: Humana Commercial |
$3.89
|
| Rate for Payer: Humana KY Medicaid |
$1.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.03
|
| Rate for Payer: Ohio Health Group HMO |
$3.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.42
|
| Rate for Payer: PHCS Commercial |
$4.40
|
| Rate for Payer: United Healthcare All Payer |
$4.03
|
|
|
PRIMACOR 5MG (10MG/10ML VIAL)
|
Facility
|
OP
|
$115.12
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.97 |
| Max. Negotiated Rate |
$110.52 |
| Rate for Payer: Aetna Commercial |
$88.64
|
| Rate for Payer: Anthem Medicaid |
$39.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.79
|
| Rate for Payer: Cash Price |
$57.56
|
| Rate for Payer: Cigna Commercial |
$95.55
|
| Rate for Payer: First Health Commercial |
$109.36
|
| Rate for Payer: Humana Commercial |
$97.85
|
| Rate for Payer: Humana KY Medicaid |
$39.59
|
| Rate for Payer: Kentucky WC Medicaid |
$39.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.31
|
| Rate for Payer: Ohio Health Group HMO |
$86.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.69
|
| Rate for Payer: PHCS Commercial |
$110.52
|
| Rate for Payer: United Healthcare All Payer |
$101.31
|
|
|
PRIMACOR 5MG (10MG/10ML VIAL)
|
Facility
|
IP
|
$115.12
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002241
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.97 |
| Max. Negotiated Rate |
$110.52 |
| Rate for Payer: Aetna Commercial |
$88.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$89.79
|
| Rate for Payer: Cash Price |
$57.56
|
| Rate for Payer: Cigna Commercial |
$95.55
|
| Rate for Payer: First Health Commercial |
$109.36
|
| Rate for Payer: Humana Commercial |
$97.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$94.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$101.31
|
| Rate for Payer: Ohio Health Group HMO |
$86.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.97
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.69
|
| Rate for Payer: PHCS Commercial |
$110.52
|
| Rate for Payer: United Healthcare All Payer |
$101.31
|
|
|
PRIMACORMILRINONE5MG200MG/DEX
|
Facility
|
OP
|
$116.50
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$111.84 |
| Rate for Payer: Aetna Commercial |
$89.70
|
| Rate for Payer: Anthem Medicaid |
$40.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.87
|
| Rate for Payer: Cash Price |
$58.25
|
| Rate for Payer: Cigna Commercial |
$96.70
|
| Rate for Payer: First Health Commercial |
$110.68
|
| Rate for Payer: Humana Commercial |
$99.02
|
| Rate for Payer: Humana KY Medicaid |
$40.06
|
| Rate for Payer: Kentucky WC Medicaid |
$40.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.52
|
| Rate for Payer: Ohio Health Group HMO |
$87.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.12
|
| Rate for Payer: PHCS Commercial |
$111.84
|
| Rate for Payer: United Healthcare All Payer |
$102.52
|
|
|
PRIMACORMILRINONE5MG200MG/DEX
|
Facility
|
IP
|
$116.50
|
|
|
Service Code
|
HCPCS J2260
|
| Hospital Charge Code |
25002240
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$111.84 |
| Rate for Payer: Aetna Commercial |
$89.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$90.87
|
| Rate for Payer: Cash Price |
$58.25
|
| Rate for Payer: Cigna Commercial |
$96.70
|
| Rate for Payer: First Health Commercial |
$110.68
|
| Rate for Payer: Humana Commercial |
$99.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$85.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.52
|
| Rate for Payer: Ohio Health Group HMO |
$87.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.12
|
| Rate for Payer: PHCS Commercial |
$111.84
|
| Rate for Payer: United Healthcare All Payer |
$102.52
|
|
|
PRIM ART M-THRMBC 1ST VSL
|
Facility
|
IP
|
$3,100.00
|
|
|
Service Code
|
HCPCS 37184
|
| Hospital Charge Code |
76101525
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.00 |
| Max. Negotiated Rate |
$2,976.00 |
| Rate for Payer: Aetna Commercial |
$2,387.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,418.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$2,573.00
|
| Rate for Payer: First Health Commercial |
$2,945.00
|
| Rate for Payer: Humana Commercial |
$2,635.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,542.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,287.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$930.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,728.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$961.00
|
| Rate for Payer: PHCS Commercial |
$2,976.00
|
| Rate for Payer: United Healthcare All Payer |
$2,728.00
|
|
|
PRIM ART M-THRMBC 1ST VSL
|
Facility
|
OP
|
$3,100.00
|
|
|
Service Code
|
HCPCS 37184
|
| Hospital Charge Code |
76101525
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.00 |
| Max. Negotiated Rate |
$21,228.97 |
| Rate for Payer: Aetna Commercial |
$2,387.00
|
| Rate for Payer: Anthem Medicaid |
$1,066.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,163.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,418.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,228.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,470.79
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$2,573.00
|
| Rate for Payer: First Health Commercial |
$2,945.00
|
| Rate for Payer: Humana Commercial |
$2,635.00
|
| Rate for Payer: Humana KY Medicaid |
$1,066.09
|
| Rate for Payer: Humana Medicare Advantage |
$15,163.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,076.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,542.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,287.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,196.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,087.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,728.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,325.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$620.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$403.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$961.00
|
| Rate for Payer: PHCS Commercial |
$2,976.00
|
| Rate for Payer: United Healthcare All Payer |
$2,728.00
|
|
|
PRIM ART M-THRMBC 1ST VSL
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 37184
|
| Hospital Charge Code |
76101525
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.20 |
| Max. Negotiated Rate |
$3,100.00 |
| Rate for Payer: Aetna Commercial |
$725.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$332.20
|
| Rate for Payer: Anthem Medicaid |
$356.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,100.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$668.09
|
| Rate for Payer: Healthspan PPO |
$2,801.50
|
| Rate for Payer: Humana Medicaid |
$356.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$604.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$364.06
|
| Rate for Payer: Molina Healthcare Passport |
$356.92
|
| Rate for Payer: Multiplan PHCS |
$1,860.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,170.00
|
| Rate for Payer: UHCCP Medicaid |
$348.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$360.49
|
|
|
PRIM ART M-THRMBC 1ST VSL(P
|
Professional
|
Both
|
$3,100.00
|
|
|
Service Code
|
HCPCS 37184
|
| Hospital Charge Code |
761P1525
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$332.20 |
| Max. Negotiated Rate |
$3,100.00 |
| Rate for Payer: Aetna Commercial |
$725.36
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$332.20
|
| Rate for Payer: Anthem Medicaid |
$356.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,100.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cash Price |
$1,550.00
|
| Rate for Payer: Cigna Commercial |
$668.09
|
| Rate for Payer: Healthspan PPO |
$2,801.50
|
| Rate for Payer: Humana Medicaid |
$356.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$604.83
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$364.06
|
| Rate for Payer: Molina Healthcare Passport |
$356.92
|
| Rate for Payer: Multiplan PHCS |
$1,860.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,170.00
|
| Rate for Payer: UHCCP Medicaid |
$348.81
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$360.49
|
|
|
PRIM ART M-THRMBC SBSQ VSL
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 37185
|
| Hospital Charge Code |
76101526
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
PRIM ART M-THRMBC SBSQ VSL
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 37185
|
| Hospital Charge Code |
76101526
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.38 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$267.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.38
|
| Rate for Payer: Anthem Medicaid |
$131.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$245.07
|
| Rate for Payer: Healthspan PPO |
$928.12
|
| Rate for Payer: Humana Medicaid |
$131.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$224.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.70
|
| Rate for Payer: Molina Healthcare Passport |
$131.08
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$128.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.39
|
|
|
PRIM ART M-THRMBC SBSQ VSL
|
Facility
|
OP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 37185
|
| Hospital Charge Code |
76101526
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem Medicaid |
$343.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Humana KY Medicaid |
$343.90
|
| Rate for Payer: Kentucky WC Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$350.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
PRIM ART M-THRMBC SBSQ VSL(P
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 37185
|
| Hospital Charge Code |
761P1526
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$122.38 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$267.46
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$122.38
|
| Rate for Payer: Anthem Medicaid |
$131.08
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$245.07
|
| Rate for Payer: Healthspan PPO |
$928.12
|
| Rate for Payer: Humana Medicaid |
$131.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$224.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$133.70
|
| Rate for Payer: Molina Healthcare Passport |
$131.08
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$128.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$132.39
|
|
|
PRIMARY HEMI MAND PLATE RIGH
|
Facility
|
OP
|
$4,468.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$580.84 |
| Max. Negotiated Rate |
$4,289.28 |
| Rate for Payer: Aetna Commercial |
$3,440.36
|
| Rate for Payer: Anthem Medicaid |
$1,536.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,485.04
|
| Rate for Payer: Cash Price |
$2,234.00
|
| Rate for Payer: Cigna Commercial |
$3,708.44
|
| Rate for Payer: First Health Commercial |
$4,244.60
|
| Rate for Payer: Humana Commercial |
$3,797.80
|
| Rate for Payer: Humana KY Medicaid |
$1,536.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,552.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,663.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,297.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,340.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,567.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,931.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$893.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,385.08
|
| Rate for Payer: PHCS Commercial |
$4,289.28
|
| Rate for Payer: United Healthcare All Payer |
$3,931.84
|
|
|
PRIMARY HEMI MAND PLATE RIGH
|
Facility
|
IP
|
$4,468.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$580.84 |
| Max. Negotiated Rate |
$4,289.28 |
| Rate for Payer: Aetna Commercial |
$3,440.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,485.04
|
| Rate for Payer: Cash Price |
$2,234.00
|
| Rate for Payer: Cigna Commercial |
$3,708.44
|
| Rate for Payer: First Health Commercial |
$4,244.60
|
| Rate for Payer: Humana Commercial |
$3,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,663.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,297.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,340.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,931.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,351.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$893.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$580.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,385.08
|
| Rate for Payer: PHCS Commercial |
$4,289.28
|
| Rate for Payer: United Healthcare All Payer |
$3,931.84
|
|
|
PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, NON-INTRACRANIAL, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); INITIAL VESSEL
|
Facility
|
OP
|
$21,228.97
|
|
|
Service Code
|
CPT 37184
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$15,163.55 |
| Max. Negotiated Rate |
$21,228.97 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,163.55
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,228.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,470.79
|
| Rate for Payer: Humana Medicare Advantage |
$15,163.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,196.26
|
|
|
PRIMATRIX 0.2*26.5
|
Facility
|
OP
|
$2,166.67
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$281.67 |
| Max. Negotiated Rate |
$2,080.00 |
| Rate for Payer: Aetna Commercial |
$1,668.34
|
| Rate for Payer: Anthem Medicaid |
$745.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,690.00
|
| Rate for Payer: Cash Price |
$1,083.33
|
| Rate for Payer: Cigna Commercial |
$1,798.34
|
| Rate for Payer: First Health Commercial |
$2,058.34
|
| Rate for Payer: Humana Commercial |
$1,841.67
|
| Rate for Payer: Humana KY Medicaid |
$745.12
|
| Rate for Payer: Kentucky WC Medicaid |
$752.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,776.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$760.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,906.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$433.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$671.67
|
| Rate for Payer: PHCS Commercial |
$2,080.00
|
| Rate for Payer: United Healthcare All Payer |
$1,906.67
|
|
|
PRIMATRIX 0.2*26.5
|
Facility
|
IP
|
$2,166.67
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$281.67 |
| Max. Negotiated Rate |
$2,080.00 |
| Rate for Payer: Aetna Commercial |
$1,668.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,690.00
|
| Rate for Payer: Cash Price |
$1,083.33
|
| Rate for Payer: Cigna Commercial |
$1,798.34
|
| Rate for Payer: First Health Commercial |
$2,058.34
|
| Rate for Payer: Humana Commercial |
$1,841.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,776.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,599.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,906.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$433.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$281.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$671.67
|
| Rate for Payer: PHCS Commercial |
$2,080.00
|
| Rate for Payer: United Healthcare All Payer |
$1,906.67
|
|
