|
SELCT PRI PORHUM STEM 11.5*125
|
Facility
|
IP
|
$23,320.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,031.61 |
| Max. Negotiated Rate |
$22,387.30 |
| Rate for Payer: Aetna Commercial |
$17,956.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,189.68
|
| Rate for Payer: Cash Price |
$11,660.05
|
| Rate for Payer: Cigna Commercial |
$19,355.68
|
| Rate for Payer: First Health Commercial |
$22,154.10
|
| Rate for Payer: Humana Commercial |
$19,822.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,122.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,210.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,996.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,521.69
|
| Rate for Payer: Ohio Health Group HMO |
$17,490.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,664.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,031.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,229.23
|
| Rate for Payer: PHCS Commercial |
$22,387.30
|
| Rate for Payer: United Healthcare All Payer |
$20,521.69
|
|
|
SELCT PRI POR HUM STEM 8.5*125
|
Facility
|
IP
|
$23,320.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,031.61 |
| Max. Negotiated Rate |
$22,387.30 |
| Rate for Payer: Aetna Commercial |
$17,956.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,189.68
|
| Rate for Payer: Cash Price |
$11,660.05
|
| Rate for Payer: Cigna Commercial |
$19,355.68
|
| Rate for Payer: First Health Commercial |
$22,154.10
|
| Rate for Payer: Humana Commercial |
$19,822.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,122.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,210.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,996.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,521.69
|
| Rate for Payer: Ohio Health Group HMO |
$17,490.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,664.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,031.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,229.23
|
| Rate for Payer: PHCS Commercial |
$22,387.30
|
| Rate for Payer: United Healthcare All Payer |
$20,521.69
|
|
|
SELCT PRI POR HUM STEM 8.5*125
|
Facility
|
OP
|
$23,320.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,031.61 |
| Max. Negotiated Rate |
$22,387.30 |
| Rate for Payer: Aetna Commercial |
$17,956.48
|
| Rate for Payer: Anthem Medicaid |
$8,019.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,189.68
|
| Rate for Payer: Cash Price |
$11,660.05
|
| Rate for Payer: Cigna Commercial |
$19,355.68
|
| Rate for Payer: First Health Commercial |
$22,154.10
|
| Rate for Payer: Humana Commercial |
$19,822.08
|
| Rate for Payer: Humana KY Medicaid |
$8,019.78
|
| Rate for Payer: Kentucky WC Medicaid |
$8,101.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,122.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,210.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,996.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,180.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,521.69
|
| Rate for Payer: Ohio Health Group HMO |
$17,490.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,664.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,031.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,229.23
|
| Rate for Payer: PHCS Commercial |
$22,387.30
|
| Rate for Payer: United Healthcare All Payer |
$20,521.69
|
|
|
SELECT COCR HUM STEM 14.5*125
|
Facility
|
OP
|
$18,560.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.85 |
| Max. Negotiated Rate |
$17,817.98 |
| Rate for Payer: Aetna Commercial |
$14,291.51
|
| Rate for Payer: Anthem Medicaid |
$6,382.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,477.11
|
| Rate for Payer: Cash Price |
$9,280.20
|
| Rate for Payer: Cigna Commercial |
$15,405.13
|
| Rate for Payer: First Health Commercial |
$17,632.38
|
| Rate for Payer: Humana Commercial |
$15,776.34
|
| Rate for Payer: Humana KY Medicaid |
$6,382.92
|
| Rate for Payer: Kentucky WC Medicaid |
$6,447.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,219.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,697.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,568.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,510.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,333.15
|
| Rate for Payer: Ohio Health Group HMO |
$13,920.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,712.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,412.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,753.72
|
| Rate for Payer: PHCS Commercial |
$17,817.98
|
| Rate for Payer: United Healthcare All Payer |
$16,333.15
|
|
|
SELECT COCR HUM STEM 14.5*125
|
Facility
|
IP
|
$18,560.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,412.85 |
| Max. Negotiated Rate |
$17,817.98 |
| Rate for Payer: Aetna Commercial |
$14,291.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,477.11
|
| Rate for Payer: Cash Price |
$9,280.20
|
| Rate for Payer: Cigna Commercial |
$15,405.13
|
| Rate for Payer: First Health Commercial |
$17,632.38
|
| Rate for Payer: Humana Commercial |
$15,776.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,219.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,697.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,568.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,333.15
|
| Rate for Payer: Ohio Health Group HMO |
$13,920.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,712.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,412.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,753.72
|
| Rate for Payer: PHCS Commercial |
$17,817.98
|
| Rate for Payer: United Healthcare All Payer |
$16,333.15
|
|
|
SELECT II ATTN CATH 6248V-130L
|
Facility
|
IP
|
$1,962.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.12 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$1,511.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.75
|
| Rate for Payer: Cash Price |
$981.25
|
| Rate for Payer: Cigna Commercial |
$1,628.88
|
| Rate for Payer: First Health Commercial |
$1,864.38
|
| Rate for Payer: Humana Commercial |
$1,668.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,609.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,727.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$608.38
|
| Rate for Payer: PHCS Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare All Payer |
$1,727.00
|
|
|
SELECT II ATTN CATH 6248V-130L
|
Facility
|
OP
|
$1,962.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$255.12 |
| Max. Negotiated Rate |
$1,884.00 |
| Rate for Payer: Aetna Commercial |
$1,511.12
|
| Rate for Payer: Anthem Medicaid |
$674.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,530.75
|
| Rate for Payer: Cash Price |
$981.25
|
| Rate for Payer: Cigna Commercial |
$1,628.88
|
| Rate for Payer: First Health Commercial |
$1,864.38
|
| Rate for Payer: Humana Commercial |
$1,668.12
|
| Rate for Payer: Humana KY Medicaid |
$674.90
|
| Rate for Payer: Kentucky WC Medicaid |
$681.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,609.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,448.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$588.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$688.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,727.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,471.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$255.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$608.38
|
| Rate for Payer: PHCS Commercial |
$1,884.00
|
| Rate for Payer: United Healthcare All Payer |
$1,727.00
|
|
|
SELECTIVE CATHETER PLACEMENT, SUBCLAVIAN OR INNOMINATE ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL VERTEBRAL CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAPHY OF THE CERVICOCEREBRAL ARCH, WHEN PERFORMED
|
Facility
|
OP
|
$3,858.95
|
|
|
Service Code
|
CPT 36225
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,756.39 |
| Max. Negotiated Rate |
$3,858.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
|
|
SELECTIVE CATHETER PLACEMNT
|
Facility
|
OP
|
$3,565.00
|
|
|
Service Code
|
HCPCS 36014
|
| Hospital Charge Code |
76101435
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$463.45 |
| Max. Negotiated Rate |
$3,422.40 |
| Rate for Payer: Aetna Commercial |
$2,745.05
|
| Rate for Payer: Anthem Medicaid |
$1,226.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,780.70
|
| Rate for Payer: Cash Price |
$1,782.50
|
| Rate for Payer: Cigna Commercial |
$2,958.95
|
| Rate for Payer: First Health Commercial |
$3,386.75
|
| Rate for Payer: Humana Commercial |
$3,030.25
|
| Rate for Payer: Humana KY Medicaid |
$1,226.00
|
| Rate for Payer: Kentucky WC Medicaid |
$1,238.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,923.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,630.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,069.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,250.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,137.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,673.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$713.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$463.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,105.15
|
| Rate for Payer: PHCS Commercial |
$3,422.40
|
| Rate for Payer: United Healthcare All Payer |
$3,137.20
|
|
|
SELECTIVE CATHETER PLACEMNT
|
Facility
|
IP
|
$3,565.00
|
|
|
Service Code
|
HCPCS 36014
|
| Hospital Charge Code |
76101435
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$463.45 |
| Max. Negotiated Rate |
$3,422.40 |
| Rate for Payer: Aetna Commercial |
$2,745.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,780.70
|
| Rate for Payer: Cash Price |
$1,782.50
|
| Rate for Payer: Cigna Commercial |
$2,958.95
|
| Rate for Payer: First Health Commercial |
$3,386.75
|
| Rate for Payer: Humana Commercial |
$3,030.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,923.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,630.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,069.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,137.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,673.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$713.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$463.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,105.15
|
| Rate for Payer: PHCS Commercial |
$3,422.40
|
| Rate for Payer: United Healthcare All Payer |
$3,137.20
|
|
|
SELECTIVE CATHETER PLACEMNT
|
Professional
|
Both
|
$3,565.00
|
|
|
Service Code
|
HCPCS 36014
|
| Hospital Charge Code |
76101435
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$3,565.00 |
| Rate for Payer: Aetna Commercial |
$270.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.62
|
| Rate for Payer: Anthem Medicaid |
$156.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,565.00
|
| Rate for Payer: Cash Price |
$1,782.50
|
| Rate for Payer: Cash Price |
$1,782.50
|
| Rate for Payer: Cigna Commercial |
$246.79
|
| Rate for Payer: Healthspan PPO |
$1,294.21
|
| Rate for Payer: Humana Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$197.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.46
|
| Rate for Payer: Molina Healthcare Passport |
$156.33
|
| Rate for Payer: Multiplan PHCS |
$2,139.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,495.50
|
| Rate for Payer: UHCCP Medicaid |
$122.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.89
|
|
|
SELECTIVE CATHETER PLACEMNT(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 36014
|
| Hospital Charge Code |
761P1435
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$116.62 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$270.56
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$116.62
|
| Rate for Payer: Anthem Medicaid |
$156.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$246.79
|
| Rate for Payer: Healthspan PPO |
$1,294.21
|
| Rate for Payer: Humana Medicaid |
$156.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$197.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$159.46
|
| Rate for Payer: Molina Healthcare Passport |
$156.33
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$122.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$157.89
|
|
|
SELECTIVE CATHETER PLACEMNT(T
|
Facility
|
OP
|
$2,065.00
|
|
|
Service Code
|
HCPCS 36014
|
| Hospital Charge Code |
761T1435
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$268.45 |
| Max. Negotiated Rate |
$1,982.40 |
| Rate for Payer: Aetna Commercial |
$1,590.05
|
| Rate for Payer: Anthem Medicaid |
$710.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,610.70
|
| Rate for Payer: Cash Price |
$1,032.50
|
| Rate for Payer: Cigna Commercial |
$1,713.95
|
| Rate for Payer: First Health Commercial |
$1,961.75
|
| Rate for Payer: Humana Commercial |
$1,755.25
|
| Rate for Payer: Humana KY Medicaid |
$710.15
|
| Rate for Payer: Kentucky WC Medicaid |
$717.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,693.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,523.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$619.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$724.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,817.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,548.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$413.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$640.15
|
| Rate for Payer: PHCS Commercial |
$1,982.40
|
| Rate for Payer: United Healthcare All Payer |
$1,817.20
|
|
|
SELECTIVE CATHETER PLACEMNT(T
|
Facility
|
IP
|
$2,065.00
|
|
|
Service Code
|
HCPCS 36014
|
| Hospital Charge Code |
761T1435
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$268.45 |
| Max. Negotiated Rate |
$1,982.40 |
| Rate for Payer: Aetna Commercial |
$1,590.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,610.70
|
| Rate for Payer: Cash Price |
$1,032.50
|
| Rate for Payer: Cigna Commercial |
$1,713.95
|
| Rate for Payer: First Health Commercial |
$1,961.75
|
| Rate for Payer: Humana Commercial |
$1,755.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,693.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,523.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$619.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,817.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,548.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$413.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$268.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$640.15
|
| Rate for Payer: PHCS Commercial |
$1,982.40
|
| Rate for Payer: United Healthcare All Payer |
$1,817.20
|
|
|
SELECT LONG POR HUM STEM 7*200
|
Facility
|
IP
|
$25,021.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,252.73 |
| Max. Negotiated Rate |
$24,020.16 |
| Rate for Payer: Aetna Commercial |
$19,266.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,516.38
|
| Rate for Payer: Cash Price |
$12,510.50
|
| Rate for Payer: Cigna Commercial |
$20,767.43
|
| Rate for Payer: First Health Commercial |
$23,769.95
|
| Rate for Payer: Humana Commercial |
$21,267.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,517.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,465.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,506.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,018.48
|
| Rate for Payer: Ohio Health Group HMO |
$18,765.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,004.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,252.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,756.51
|
| Rate for Payer: PHCS Commercial |
$24,020.16
|
| Rate for Payer: United Healthcare All Payer |
$22,018.48
|
|
|
SELECT LONG POR HUM STEM 7*200
|
Facility
|
OP
|
$25,021.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,252.73 |
| Max. Negotiated Rate |
$24,020.16 |
| Rate for Payer: Aetna Commercial |
$19,266.17
|
| Rate for Payer: Anthem Medicaid |
$8,604.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,516.38
|
| Rate for Payer: Cash Price |
$12,510.50
|
| Rate for Payer: Cigna Commercial |
$20,767.43
|
| Rate for Payer: First Health Commercial |
$23,769.95
|
| Rate for Payer: Humana Commercial |
$21,267.85
|
| Rate for Payer: Humana KY Medicaid |
$8,604.72
|
| Rate for Payer: Kentucky WC Medicaid |
$8,692.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,517.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,465.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,506.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,777.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,018.48
|
| Rate for Payer: Ohio Health Group HMO |
$18,765.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,004.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,252.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,756.51
|
| Rate for Payer: PHCS Commercial |
$24,020.16
|
| Rate for Payer: United Healthcare All Payer |
$22,018.48
|
|
|
SELECT PRI POR HUM STEM 10*125
|
Facility
|
IP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
SELECT PRI POR HUM STEM 10*125
|
Facility
|
OP
|
$7,716.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.15 |
| Max. Negotiated Rate |
$7,407.89 |
| Rate for Payer: Aetna Commercial |
$5,941.74
|
| Rate for Payer: Anthem Medicaid |
$2,653.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,018.91
|
| Rate for Payer: Cash Price |
$3,858.28
|
| Rate for Payer: Cigna Commercial |
$6,404.74
|
| Rate for Payer: First Health Commercial |
$7,330.72
|
| Rate for Payer: Humana Commercial |
$6,559.07
|
| Rate for Payer: Humana KY Medicaid |
$2,653.72
|
| Rate for Payer: Kentucky WC Medicaid |
$2,680.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,327.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,694.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,314.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,706.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,790.56
|
| Rate for Payer: Ohio Health Group HMO |
$5,787.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,543.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,003.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,392.13
|
| Rate for Payer: PHCS Commercial |
$7,407.89
|
| Rate for Payer: United Healthcare All Payer |
$6,790.56
|
|
|
SELENIUM 200MCG TABLET
|
Facility
|
IP
|
$4.25
|
|
|
Service Code
|
NDC 54629016300
|
| Hospital Charge Code |
25003436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
SELENIUM 200MCG TABLET
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 54629016300
|
| Hospital Charge Code |
25003436
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.08 |
| Rate for Payer: Aetna Commercial |
$3.27
|
| Rate for Payer: Anthem Medicaid |
$1.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.12
|
| Rate for Payer: Cigna Commercial |
$3.53
|
| Rate for Payer: First Health Commercial |
$4.04
|
| Rate for Payer: Humana Commercial |
$3.61
|
| Rate for Payer: Humana KY Medicaid |
$1.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.74
|
| Rate for Payer: Ohio Health Group HMO |
$3.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.32
|
| Rate for Payer: PHCS Commercial |
$4.08
|
| Rate for Payer: United Healthcare All Payer |
$3.74
|
|
|
SELENIUM 600mcg/10mL
|
Facility
|
IP
|
$954.57
|
|
|
Service Code
|
NDC 517656005
|
| Hospital Charge Code |
25004168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.09 |
| Max. Negotiated Rate |
$916.39 |
| Rate for Payer: Aetna Commercial |
$735.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$744.56
|
| Rate for Payer: Cash Price |
$477.29
|
| Rate for Payer: Cigna Commercial |
$792.29
|
| Rate for Payer: First Health Commercial |
$906.84
|
| Rate for Payer: Humana Commercial |
$811.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$782.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$704.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$286.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$840.02
|
| Rate for Payer: Ohio Health Group HMO |
$715.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$190.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$295.92
|
| Rate for Payer: PHCS Commercial |
$916.39
|
| Rate for Payer: United Healthcare All Payer |
$840.02
|
|
|
SELENIUM 600mcg/10mL
|
Facility
|
OP
|
$954.57
|
|
|
Service Code
|
NDC 517656005
|
| Hospital Charge Code |
25004168
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$124.09 |
| Max. Negotiated Rate |
$916.39 |
| Rate for Payer: Aetna Commercial |
$735.02
|
| Rate for Payer: Anthem Medicaid |
$328.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$744.56
|
| Rate for Payer: Cash Price |
$477.29
|
| Rate for Payer: Cigna Commercial |
$792.29
|
| Rate for Payer: First Health Commercial |
$906.84
|
| Rate for Payer: Humana Commercial |
$811.38
|
| Rate for Payer: Humana KY Medicaid |
$328.28
|
| Rate for Payer: Kentucky WC Medicaid |
$331.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$782.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$704.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$286.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$334.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$840.02
|
| Rate for Payer: Ohio Health Group HMO |
$715.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$190.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$124.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$295.92
|
| Rate for Payer: PHCS Commercial |
$916.39
|
| Rate for Payer: United Healthcare All Payer |
$840.02
|
|
|
SELEX/M2A-MAGNUM HIP 40MM +9
|
Facility
|
OP
|
$4,930.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$640.90 |
| Max. Negotiated Rate |
$4,732.80 |
| Rate for Payer: Aetna Commercial |
$3,796.10
|
| Rate for Payer: Anthem Medicaid |
$1,695.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,845.40
|
| Rate for Payer: Cash Price |
$2,465.00
|
| Rate for Payer: Cigna Commercial |
$4,091.90
|
| Rate for Payer: First Health Commercial |
$4,683.50
|
| Rate for Payer: Humana Commercial |
$4,190.50
|
| Rate for Payer: Humana KY Medicaid |
$1,695.43
|
| Rate for Payer: Kentucky WC Medicaid |
$1,712.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,042.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,638.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,479.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,729.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,338.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$986.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$640.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,528.30
|
| Rate for Payer: PHCS Commercial |
$4,732.80
|
| Rate for Payer: United Healthcare All Payer |
$4,338.40
|
|
|
SELEX/M2A-MAGNUM HIP 40MM +9
|
Facility
|
IP
|
$4,930.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$640.90 |
| Max. Negotiated Rate |
$4,732.80 |
| Rate for Payer: Aetna Commercial |
$3,796.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,845.40
|
| Rate for Payer: Cash Price |
$2,465.00
|
| Rate for Payer: Cigna Commercial |
$4,091.90
|
| Rate for Payer: First Health Commercial |
$4,683.50
|
| Rate for Payer: Humana Commercial |
$4,190.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,042.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,638.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,479.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,338.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$986.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$640.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,528.30
|
| Rate for Payer: PHCS Commercial |
$4,732.80
|
| Rate for Payer: United Healthcare All Payer |
$4,338.40
|
|
|
SELF CENT HEAD 41MM +5
|
Facility
|
OP
|
$8,588.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,116.56 |
| Max. Negotiated Rate |
$8,245.34 |
| Rate for Payer: Aetna Commercial |
$6,613.45
|
| Rate for Payer: Anthem Medicaid |
$2,953.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,699.34
|
| Rate for Payer: Cash Price |
$4,294.45
|
| Rate for Payer: Cigna Commercial |
$7,128.79
|
| Rate for Payer: First Health Commercial |
$8,159.46
|
| Rate for Payer: Humana Commercial |
$7,300.56
|
| Rate for Payer: Humana KY Medicaid |
$2,953.72
|
| Rate for Payer: Kentucky WC Medicaid |
$2,983.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,042.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,338.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,576.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,012.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,558.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,441.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,717.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,116.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,662.56
|
| Rate for Payer: PHCS Commercial |
$8,245.34
|
| Rate for Payer: United Healthcare All Payer |
$7,558.23
|
|
