|
SUPERA PERIPH STNT 5.5*100*120
|
Facility
|
IP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
|
SUPERA PERIPH STNT 5.5*120*120
|
Facility
|
IP
|
$7,453.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$968.99 |
| Max. Negotiated Rate |
$7,155.60 |
| Rate for Payer: Aetna Commercial |
$5,739.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,813.92
|
| Rate for Payer: Cash Price |
$3,726.88
|
| Rate for Payer: Cigna Commercial |
$6,186.61
|
| Rate for Payer: First Health Commercial |
$7,081.06
|
| Rate for Payer: Humana Commercial |
$6,335.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,112.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,500.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,236.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,559.30
|
| Rate for Payer: Ohio Health Group HMO |
$5,590.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,490.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$968.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,310.66
|
| Rate for Payer: PHCS Commercial |
$7,155.60
|
| Rate for Payer: United Healthcare All Payer |
$6,559.30
|
|
|
SUPERA PERIPH STNT 5.5*120*120
|
Facility
|
OP
|
$7,453.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$968.99 |
| Max. Negotiated Rate |
$7,155.60 |
| Rate for Payer: Aetna Commercial |
$5,739.39
|
| Rate for Payer: Anthem Medicaid |
$2,563.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,813.92
|
| Rate for Payer: Cash Price |
$3,726.88
|
| Rate for Payer: Cigna Commercial |
$6,186.61
|
| Rate for Payer: First Health Commercial |
$7,081.06
|
| Rate for Payer: Humana Commercial |
$6,335.69
|
| Rate for Payer: Humana KY Medicaid |
$2,563.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,589.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,112.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,500.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,236.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,614.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,559.30
|
| Rate for Payer: Ohio Health Group HMO |
$5,590.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,490.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$968.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,310.66
|
| Rate for Payer: PHCS Commercial |
$7,155.60
|
| Rate for Payer: United Healthcare All Payer |
$6,559.30
|
|
|
SUPERA PERIPH STNT 5.5*150*120
|
Facility
|
OP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem Medicaid |
$2,594.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Humana KY Medicaid |
$2,594.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,621.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,646.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
|
SUPERA PERIPH STNT 5.5*150*120
|
Facility
|
IP
|
$7,545.00
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$980.85 |
| Max. Negotiated Rate |
$7,243.20 |
| Rate for Payer: Aetna Commercial |
$5,809.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,885.10
|
| Rate for Payer: Cash Price |
$3,772.50
|
| Rate for Payer: Cigna Commercial |
$6,262.35
|
| Rate for Payer: First Health Commercial |
$7,167.75
|
| Rate for Payer: Humana Commercial |
$6,413.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,186.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,568.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,263.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,639.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,658.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,509.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$980.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,338.95
|
| Rate for Payer: PHCS Commercial |
$7,243.20
|
| Rate for Payer: United Healthcare All Payer |
$6,639.60
|
|
|
SUPERCROSS 90DEG. 130CM
|
Facility
|
IP
|
$3,838.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$498.94 |
| Max. Negotiated Rate |
$3,684.48 |
| Rate for Payer: Aetna Commercial |
$2,955.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.64
|
| Rate for Payer: Cash Price |
$1,919.00
|
| Rate for Payer: Cigna Commercial |
$3,185.54
|
| Rate for Payer: First Health Commercial |
$3,646.10
|
| Rate for Payer: Humana Commercial |
$3,262.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,147.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$498.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.78
|
| Rate for Payer: PHCS Commercial |
$3,684.48
|
| Rate for Payer: United Healthcare All Payer |
$3,377.44
|
|
|
SUPERCROSS 90DEG. 130CM
|
Facility
|
OP
|
$3,838.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$498.94 |
| Max. Negotiated Rate |
$3,684.48 |
| Rate for Payer: Aetna Commercial |
$2,955.26
|
| Rate for Payer: Anthem Medicaid |
$1,319.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,993.64
|
| Rate for Payer: Cash Price |
$1,919.00
|
| Rate for Payer: Cigna Commercial |
$3,185.54
|
| Rate for Payer: First Health Commercial |
$3,646.10
|
| Rate for Payer: Humana Commercial |
$3,262.30
|
| Rate for Payer: Humana KY Medicaid |
$1,319.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,333.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,147.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,832.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,151.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,346.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,377.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,878.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$767.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$498.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,189.78
|
| Rate for Payer: PHCS Commercial |
$3,684.48
|
| Rate for Payer: United Healthcare All Payer |
$3,377.44
|
|
|
SUPERIOR VENACAVAGRAM
|
Professional
|
Both
|
$1,639.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
32000168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$71.50 |
| Max. Negotiated Rate |
$1,639.00 |
| Rate for Payer: Aetna Commercial |
$407.84
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,639.00
|
| Rate for Payer: Cash Price |
$819.50
|
| Rate for Payer: Cash Price |
$819.50
|
| Rate for Payer: Cigna Commercial |
$675.61
|
| Rate for Payer: Healthspan PPO |
$382.16
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$983.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,147.30
|
| Rate for Payer: UHCCP Medicaid |
$573.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
|
|
SUPERIOR VENACAVAGRAM
|
Facility
|
IP
|
$1,639.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
32000168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$213.07 |
| Max. Negotiated Rate |
$1,573.44 |
| Rate for Payer: Aetna Commercial |
$1,262.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,278.42
|
| Rate for Payer: Cash Price |
$819.50
|
| Rate for Payer: Cigna Commercial |
$1,360.37
|
| Rate for Payer: First Health Commercial |
$1,557.05
|
| Rate for Payer: Humana Commercial |
$1,393.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,343.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,209.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$491.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,442.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,229.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$327.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$508.09
|
| Rate for Payer: PHCS Commercial |
$1,573.44
|
| Rate for Payer: United Healthcare All Payer |
$1,442.32
|
|
|
SUPERIOR VENACAVAGRAM
|
Facility
|
OP
|
$1,639.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
32000168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$213.07 |
| Max. Negotiated Rate |
$1,938.90 |
| Rate for Payer: Aetna Commercial |
$1,262.03
|
| Rate for Payer: Anthem Medicaid |
$563.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,278.42
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$819.50
|
| Rate for Payer: Cash Price |
$819.50
|
| Rate for Payer: Cigna Commercial |
$1,360.37
|
| Rate for Payer: First Health Commercial |
$1,557.05
|
| Rate for Payer: Humana Commercial |
$1,393.15
|
| Rate for Payer: Humana KY Medicaid |
$563.65
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$569.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,343.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,209.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$574.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,442.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,229.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$327.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$213.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$508.09
|
| Rate for Payer: PHCS Commercial |
$1,573.44
|
| Rate for Payer: United Healthcare All Payer |
$1,442.32
|
|
|
SUPERIOR VENACAVAGRAM(P
|
Professional
|
Both
|
$203.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
320P0168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$71.05 |
| Max. Negotiated Rate |
$675.61 |
| Rate for Payer: Aetna Commercial |
$407.84
|
| Rate for Payer: Anthem Medicaid |
$389.16
|
| Rate for Payer: Buckeye Medicare Advantage |
$203.00
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cash Price |
$101.50
|
| Rate for Payer: Cigna Commercial |
$675.61
|
| Rate for Payer: Healthspan PPO |
$382.16
|
| Rate for Payer: Humana Medicaid |
$389.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$71.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$396.94
|
| Rate for Payer: Molina Healthcare Passport |
$389.16
|
| Rate for Payer: Multiplan PHCS |
$121.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$142.10
|
| Rate for Payer: UHCCP Medicaid |
$71.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$393.05
|
|
|
SUPERIOR VENACAVAGRAM(T
|
Facility
|
OP
|
$1,436.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
320T0168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$186.68 |
| Max. Negotiated Rate |
$1,938.90 |
| Rate for Payer: Aetna Commercial |
$1,105.72
|
| Rate for Payer: Anthem Medicaid |
$493.84
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,384.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,120.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,938.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,869.66
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cigna Commercial |
$1,191.88
|
| Rate for Payer: First Health Commercial |
$1,364.20
|
| Rate for Payer: Humana Commercial |
$1,220.60
|
| Rate for Payer: Humana KY Medicaid |
$493.84
|
| Rate for Payer: Humana Medicare Advantage |
$1,384.93
|
| Rate for Payer: Kentucky WC Medicaid |
$498.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,177.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,059.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,661.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$503.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,263.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,077.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$287.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$186.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$445.16
|
| Rate for Payer: PHCS Commercial |
$1,378.56
|
| Rate for Payer: United Healthcare All Payer |
$1,263.68
|
|
|
SUPERIOR VENACAVAGRAM(T
|
Facility
|
IP
|
$1,436.00
|
|
|
Service Code
|
HCPCS 75827
|
| Hospital Charge Code |
320T0168
|
|
Hospital Revenue Code
|
321
|
| Min. Negotiated Rate |
$186.68 |
| Max. Negotiated Rate |
$1,378.56 |
| Rate for Payer: Aetna Commercial |
$1,105.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,120.08
|
| Rate for Payer: Cash Price |
$718.00
|
| Rate for Payer: Cigna Commercial |
$1,191.88
|
| Rate for Payer: First Health Commercial |
$1,364.20
|
| Rate for Payer: Humana Commercial |
$1,220.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,177.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,059.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$430.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,263.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,077.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$287.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$186.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$445.16
|
| Rate for Payer: PHCS Commercial |
$1,378.56
|
| Rate for Payer: United Healthcare All Payer |
$1,263.68
|
|
|
SUPPORT FOR ORGAN DONOR
|
Professional
|
Both
|
$8.00
|
|
|
Service Code
|
HCPCS 01990
|
| Hospital Charge Code |
37000001
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$8.00
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Multiplan PHCS |
$4.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.60
|
| Rate for Payer: UHCCP Medicaid |
$2.80
|
|
|
SUPPORT FOR ORGAN DONOR
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
HCPCS 1990
|
| Hospital Charge Code |
37000001
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.24
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$6.64
|
| Rate for Payer: First Health Commercial |
$7.60
|
| Rate for Payer: Humana Commercial |
$6.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.04
|
| Rate for Payer: Ohio Health Group HMO |
$6.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.48
|
| Rate for Payer: PHCS Commercial |
$7.68
|
| Rate for Payer: United Healthcare All Payer |
$7.04
|
|
|
SUPPORT FOR ORGAN DONOR
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
HCPCS 1990
|
| Hospital Charge Code |
37000001
|
|
Hospital Revenue Code
|
370
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$7.68 |
| Rate for Payer: Aetna Commercial |
$6.16
|
| Rate for Payer: Anthem Medicaid |
$2.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6.24
|
| Rate for Payer: Cash Price |
$4.00
|
| Rate for Payer: Cigna Commercial |
$6.64
|
| Rate for Payer: First Health Commercial |
$7.60
|
| Rate for Payer: Humana Commercial |
$6.80
|
| Rate for Payer: Humana KY Medicaid |
$2.75
|
| Rate for Payer: Kentucky WC Medicaid |
$2.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$2.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.04
|
| Rate for Payer: Ohio Health Group HMO |
$6.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.48
|
| Rate for Payer: PHCS Commercial |
$7.68
|
| Rate for Payer: United Healthcare All Payer |
$7.04
|
|
|
SUPRANE LIQ DESFLURANE EA1/2HR
|
Facility
|
IP
|
$330.22
|
|
|
Service Code
|
NDC 10019064134
|
| Hospital Charge Code |
25003501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.93 |
| Max. Negotiated Rate |
$317.01 |
| Rate for Payer: Aetna Commercial |
$254.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.57
|
| Rate for Payer: Cash Price |
$165.11
|
| Rate for Payer: Cigna Commercial |
$274.08
|
| Rate for Payer: First Health Commercial |
$313.71
|
| Rate for Payer: Humana Commercial |
$280.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.59
|
| Rate for Payer: Ohio Health Group HMO |
$247.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.37
|
| Rate for Payer: PHCS Commercial |
$317.01
|
| Rate for Payer: United Healthcare All Payer |
$290.59
|
|
|
SUPRANE LIQ DESFLURANE EA1/2HR
|
Facility
|
OP
|
$330.22
|
|
|
Service Code
|
NDC 10019064134
|
| Hospital Charge Code |
25003501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.93 |
| Max. Negotiated Rate |
$317.01 |
| Rate for Payer: Aetna Commercial |
$254.27
|
| Rate for Payer: Anthem Medicaid |
$113.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.57
|
| Rate for Payer: Cash Price |
$165.11
|
| Rate for Payer: Cigna Commercial |
$274.08
|
| Rate for Payer: First Health Commercial |
$313.71
|
| Rate for Payer: Humana Commercial |
$280.69
|
| Rate for Payer: Humana KY Medicaid |
$113.56
|
| Rate for Payer: Kentucky WC Medicaid |
$114.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.59
|
| Rate for Payer: Ohio Health Group HMO |
$247.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.37
|
| Rate for Payer: PHCS Commercial |
$317.01
|
| Rate for Payer: United Healthcare All Payer |
$290.59
|
|
|
SUREGLIDE GUIDEWIRE STR .035
|
Facility
|
IP
|
$795.26
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$763.45 |
| Rate for Payer: Aetna Commercial |
$612.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.30
|
| Rate for Payer: Cash Price |
$397.63
|
| Rate for Payer: Cigna Commercial |
$660.07
|
| Rate for Payer: First Health Commercial |
$755.50
|
| Rate for Payer: Humana Commercial |
$675.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$652.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.83
|
| Rate for Payer: Ohio Health Group HMO |
$596.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.53
|
| Rate for Payer: PHCS Commercial |
$763.45
|
| Rate for Payer: United Healthcare All Payer |
$699.83
|
|
|
SUREGLIDE GUIDEWIRE STR .035
|
Facility
|
OP
|
$795.26
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$103.38 |
| Max. Negotiated Rate |
$763.45 |
| Rate for Payer: Aetna Commercial |
$612.35
|
| Rate for Payer: Anthem Medicaid |
$273.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$620.30
|
| Rate for Payer: Cash Price |
$397.63
|
| Rate for Payer: Cigna Commercial |
$660.07
|
| Rate for Payer: First Health Commercial |
$755.50
|
| Rate for Payer: Humana Commercial |
$675.97
|
| Rate for Payer: Humana KY Medicaid |
$273.49
|
| Rate for Payer: Kentucky WC Medicaid |
$276.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$652.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$586.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$238.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$278.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$699.83
|
| Rate for Payer: Ohio Health Group HMO |
$596.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$103.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$246.53
|
| Rate for Payer: PHCS Commercial |
$763.45
|
| Rate for Payer: United Healthcare All Payer |
$699.83
|
|
|
SURFAK(DOCUSATE CAL 240MG/1CAP
|
Facility
|
IP
|
$4.26
|
|
|
Service Code
|
NDC 904699760
|
| Hospital Charge Code |
25001453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| 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 |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| 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 |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
SURFAK(DOCUSATE CAL 240MG/1CAP
|
Facility
|
OP
|
$4.26
|
|
|
Service Code
|
NDC 904699760
|
| Hospital Charge Code |
25001453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.09 |
| Rate for Payer: Aetna Commercial |
$3.28
|
| Rate for Payer: Anthem Medicaid |
$1.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.32
|
| Rate for Payer: Cash Price |
$2.13
|
| Rate for Payer: Cigna Commercial |
$3.54
|
| Rate for Payer: First Health Commercial |
$4.05
|
| Rate for Payer: Humana Commercial |
$3.62
|
| Rate for Payer: Humana KY Medicaid |
$1.47
|
| Rate for Payer: Kentucky WC Medicaid |
$1.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.49
|
| 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 |
$3.75
|
| Rate for Payer: Ohio Health Group HMO |
$3.20
|
| 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 |
$4.09
|
| Rate for Payer: United Healthcare All Payer |
$3.75
|
|
|
SURG DX EXAM ANORECTAL
|
Facility
|
OP
|
$330.00
|
|
|
Service Code
|
HCPCS 45990
|
| Hospital Charge Code |
76101909
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$3,399.27 |
| Rate for Payer: Aetna Commercial |
$254.10
|
| Rate for Payer: Anthem Medicaid |
$113.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,428.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,399.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,277.87
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$273.90
|
| Rate for Payer: First Health Commercial |
$313.50
|
| Rate for Payer: Humana Commercial |
$280.50
|
| Rate for Payer: Humana KY Medicaid |
$113.49
|
| Rate for Payer: Humana Medicare Advantage |
$2,428.05
|
| Rate for Payer: Kentucky WC Medicaid |
$114.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,913.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.40
|
| Rate for Payer: Ohio Health Group HMO |
$247.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.30
|
| Rate for Payer: PHCS Commercial |
$316.80
|
| Rate for Payer: United Healthcare All Payer |
$290.40
|
|
|
SURG DX EXAM ANORECTAL
|
Professional
|
Both
|
$330.00
|
|
|
Service Code
|
HCPCS 45990
|
| Hospital Charge Code |
76101909
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$77.97 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Aetna Commercial |
$157.23
|
| Rate for Payer: Anthem Medicaid |
$77.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$330.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$148.84
|
| Rate for Payer: Healthspan PPO |
$132.60
|
| Rate for Payer: Humana Medicaid |
$77.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$137.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$79.53
|
| Rate for Payer: Molina Healthcare Passport |
$77.97
|
| Rate for Payer: Multiplan PHCS |
$198.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.00
|
| Rate for Payer: UHCCP Medicaid |
$115.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$78.75
|
|
|
SURG DX EXAM ANORECTAL
|
Facility
|
IP
|
$330.00
|
|
|
Service Code
|
HCPCS 45990
|
| Hospital Charge Code |
76101909
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$316.80 |
| Rate for Payer: Aetna Commercial |
$254.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.40
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna Commercial |
$273.90
|
| Rate for Payer: First Health Commercial |
$313.50
|
| Rate for Payer: Humana Commercial |
$280.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.40
|
| Rate for Payer: Ohio Health Group HMO |
$247.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$66.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$42.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.30
|
| Rate for Payer: PHCS Commercial |
$316.80
|
| Rate for Payer: United Healthcare All Payer |
$290.40
|
|
