|
THROMBECTOMY - DIRECT OR WITH
|
Facility
|
IP
|
$2,303.00
|
|
|
Service Code
|
HCPCS 34451
|
| Hospital Charge Code |
76101343
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.39 |
| Max. Negotiated Rate |
$2,210.88 |
| Rate for Payer: Aetna Commercial |
$1,773.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,796.34
|
| Rate for Payer: Cash Price |
$1,151.50
|
| Rate for Payer: Cigna Commercial |
$1,911.49
|
| Rate for Payer: First Health Commercial |
$2,187.85
|
| Rate for Payer: Humana Commercial |
$1,957.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,888.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,699.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,026.64
|
| Rate for Payer: Ohio Health Group HMO |
$1,727.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.93
|
| Rate for Payer: PHCS Commercial |
$2,210.88
|
| Rate for Payer: United Healthcare All Payer |
$2,026.64
|
|
|
THROMBECTOMY - DIRECT OR WITH
|
Professional
|
Both
|
$2,303.00
|
|
|
Service Code
|
HCPCS 34451
|
| Hospital Charge Code |
76101343
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$724.01 |
| Max. Negotiated Rate |
$2,655.19 |
| Rate for Payer: Aetna Commercial |
$2,655.19
|
| Rate for Payer: Anthem Medicaid |
$724.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,303.00
|
| Rate for Payer: Cash Price |
$1,151.50
|
| Rate for Payer: Cash Price |
$1,151.50
|
| Rate for Payer: Cigna Commercial |
$2,535.50
|
| Rate for Payer: Healthspan PPO |
$2,610.57
|
| Rate for Payer: Humana Medicaid |
$724.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,026.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$738.49
|
| Rate for Payer: Molina Healthcare Passport |
$724.01
|
| Rate for Payer: Multiplan PHCS |
$1,381.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,612.10
|
| Rate for Payer: UHCCP Medicaid |
$806.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$731.25
|
|
|
THROMBECTOMY - DIRECT OR WITH
|
Professional
|
Both
|
$7,860.62
|
|
|
Service Code
|
HCPCS 34490
|
| Hospital Charge Code |
76101344
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$423.44 |
| Max. Negotiated Rate |
$7,860.62 |
| Rate for Payer: Aetna Commercial |
$1,060.60
|
| Rate for Payer: Anthem Medicaid |
$423.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,860.62
|
| Rate for Payer: Cash Price |
$3,930.31
|
| Rate for Payer: Cash Price |
$3,930.31
|
| Rate for Payer: Cigna Commercial |
$1,022.39
|
| Rate for Payer: Healthspan PPO |
$1,042.78
|
| Rate for Payer: Humana Medicaid |
$423.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$831.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$431.91
|
| Rate for Payer: Molina Healthcare Passport |
$423.44
|
| Rate for Payer: Multiplan PHCS |
$4,716.37
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5,502.43
|
| Rate for Payer: UHCCP Medicaid |
$2,751.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$427.67
|
|
|
THROMBECTOMY - DIRECT OR WIT(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 34490
|
| Hospital Charge Code |
761P1344
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$423.44 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,060.60
|
| Rate for Payer: Anthem Medicaid |
$423.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,022.39
|
| Rate for Payer: Healthspan PPO |
$1,042.78
|
| Rate for Payer: Humana Medicaid |
$423.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$831.21
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$431.91
|
| Rate for Payer: Molina Healthcare Passport |
$423.44
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$427.67
|
|
|
THROMBECTOMY - DIRECT OR WIT(P
|
Professional
|
Both
|
$2,303.00
|
|
|
Service Code
|
HCPCS 34451
|
| Hospital Charge Code |
761P1343
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$724.01 |
| Max. Negotiated Rate |
$2,655.19 |
| Rate for Payer: Aetna Commercial |
$2,655.19
|
| Rate for Payer: Anthem Medicaid |
$724.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,303.00
|
| Rate for Payer: Cash Price |
$1,151.50
|
| Rate for Payer: Cash Price |
$1,151.50
|
| Rate for Payer: Cigna Commercial |
$2,535.50
|
| Rate for Payer: Healthspan PPO |
$2,610.57
|
| Rate for Payer: Humana Medicaid |
$724.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,026.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$738.49
|
| Rate for Payer: Molina Healthcare Passport |
$724.01
|
| Rate for Payer: Multiplan PHCS |
$1,381.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,612.10
|
| Rate for Payer: UHCCP Medicaid |
$806.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$731.25
|
|
|
THROMBECTOMY - DIRECT OR WIT(T
|
Facility
|
IP
|
$6,260.62
|
|
|
Service Code
|
HCPCS 34490
|
| Hospital Charge Code |
761T1344
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$813.88 |
| Max. Negotiated Rate |
$6,010.20 |
| Rate for Payer: Aetna Commercial |
$4,820.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,883.28
|
| Rate for Payer: Cash Price |
$3,130.31
|
| Rate for Payer: Cigna Commercial |
$5,196.31
|
| Rate for Payer: First Health Commercial |
$5,947.59
|
| Rate for Payer: Humana Commercial |
$5,321.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,133.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,620.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,878.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,509.35
|
| Rate for Payer: Ohio Health Group HMO |
$4,695.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,252.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$813.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,940.79
|
| Rate for Payer: PHCS Commercial |
$6,010.20
|
| Rate for Payer: United Healthcare All Payer |
$5,509.35
|
|
|
THROMBECTOMY - DIRECT OR WIT(T
|
Facility
|
OP
|
$6,260.62
|
|
|
Service Code
|
HCPCS 34490
|
| Hospital Charge Code |
761T1344
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$813.88 |
| Max. Negotiated Rate |
$6,010.20 |
| Rate for Payer: Aetna Commercial |
$4,820.68
|
| Rate for Payer: Anthem Medicaid |
$2,153.03
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,883.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$3,130.31
|
| Rate for Payer: Cash Price |
$3,130.31
|
| Rate for Payer: Cigna Commercial |
$5,196.31
|
| Rate for Payer: First Health Commercial |
$5,947.59
|
| Rate for Payer: Humana Commercial |
$5,321.53
|
| Rate for Payer: Humana KY Medicaid |
$2,153.03
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$2,174.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,133.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,620.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,196.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,509.35
|
| Rate for Payer: Ohio Health Group HMO |
$4,695.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,252.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$813.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,940.79
|
| Rate for Payer: PHCS Commercial |
$6,010.20
|
| Rate for Payer: United Healthcare All Payer |
$5,509.35
|
|
|
THROMBECTOMY - OPEN - ARTERI
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
HCPCS 36831
|
| Hospital Charge Code |
76101510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$725.72 |
| Rate for Payer: Aetna Commercial |
$725.72
|
| Rate for Payer: Anthem Medicaid |
$322.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$675.00
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$694.76
|
| Rate for Payer: Healthspan PPO |
$580.28
|
| Rate for Payer: Humana Medicaid |
$322.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$611.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$329.30
|
| Rate for Payer: Molina Healthcare Passport |
$322.84
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$472.50
|
| Rate for Payer: UHCCP Medicaid |
$236.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$326.07
|
|
|
THROMBECTOMY - OPEN - ARTERI
|
Facility
|
OP
|
$675.00
|
|
|
Service Code
|
HCPCS 36831
|
| Hospital Charge Code |
76101510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.75 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Aetna Commercial |
$519.75
|
| Rate for Payer: Anthem Medicaid |
$232.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$526.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$560.25
|
| Rate for Payer: First Health Commercial |
$641.25
|
| Rate for Payer: Humana Commercial |
$573.75
|
| Rate for Payer: Humana KY Medicaid |
$232.13
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Kentucky WC Medicaid |
$234.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$553.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$236.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.00
|
| Rate for Payer: Ohio Health Group HMO |
$506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.25
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
|
THROMBECTOMY - OPEN - ARTERI
|
Facility
|
IP
|
$675.00
|
|
|
Service Code
|
HCPCS 36831
|
| Hospital Charge Code |
76101510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.75 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$519.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$526.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$560.25
|
| Rate for Payer: First Health Commercial |
$641.25
|
| Rate for Payer: Humana Commercial |
$573.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$553.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.00
|
| Rate for Payer: Ohio Health Group HMO |
$506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$209.25
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
|
THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$6,652.97
|
|
|
Service Code
|
CPT 36831
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,752.12 |
| Max. Negotiated Rate |
$6,652.97 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,752.12
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,652.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,415.36
|
| Rate for Payer: Humana Medicare Advantage |
$4,752.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,702.54
|
|
|
THROMBECTOMY - OPEN - ARTERI(P
|
Professional
|
Both
|
$675.00
|
|
|
Service Code
|
HCPCS 36831
|
| Hospital Charge Code |
761P1510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$725.72 |
| Rate for Payer: Aetna Commercial |
$725.72
|
| Rate for Payer: Anthem Medicaid |
$322.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$675.00
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$694.76
|
| Rate for Payer: Healthspan PPO |
$580.28
|
| Rate for Payer: Humana Medicaid |
$322.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$611.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$329.30
|
| Rate for Payer: Molina Healthcare Passport |
$322.84
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$472.50
|
| Rate for Payer: UHCCP Medicaid |
$236.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$326.07
|
|
|
THROMBINAR(THROMBI 5000U/1VIAL
|
Facility
|
IP
|
$144.13
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
25003520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$138.36 |
| Rate for Payer: Aetna Commercial |
$110.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.42
|
| Rate for Payer: Cash Price |
$72.06
|
| Rate for Payer: Cigna Commercial |
$119.63
|
| Rate for Payer: First Health Commercial |
$136.92
|
| Rate for Payer: Humana Commercial |
$122.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.83
|
| Rate for Payer: Ohio Health Group HMO |
$108.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.68
|
| Rate for Payer: PHCS Commercial |
$138.36
|
| Rate for Payer: United Healthcare All Payer |
$126.83
|
|
|
THROMBINAR(THROMBI 5000U/1VIAL
|
Facility
|
OP
|
$144.13
|
|
|
Service Code
|
NDC 60793021505
|
| Hospital Charge Code |
25003520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$138.36 |
| Rate for Payer: Aetna Commercial |
$110.98
|
| Rate for Payer: Anthem Medicaid |
$49.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.42
|
| Rate for Payer: Cash Price |
$72.06
|
| Rate for Payer: Cigna Commercial |
$119.63
|
| Rate for Payer: First Health Commercial |
$136.92
|
| Rate for Payer: Humana Commercial |
$122.51
|
| Rate for Payer: Humana KY Medicaid |
$49.57
|
| Rate for Payer: Kentucky WC Medicaid |
$50.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.83
|
| Rate for Payer: Ohio Health Group HMO |
$108.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.83
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.68
|
| Rate for Payer: PHCS Commercial |
$138.36
|
| Rate for Payer: United Healthcare All Payer |
$126.83
|
|
|
THROMBINAR(THROMBI 5000U/1VIAL
|
Facility
|
OP
|
$468.70
|
|
|
Service Code
|
NDC 338032201
|
| Hospital Charge Code |
25003520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.93 |
| Max. Negotiated Rate |
$449.95 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Anthem Medicaid |
$161.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.59
|
| Rate for Payer: Cash Price |
$234.35
|
| Rate for Payer: Cigna Commercial |
$389.02
|
| Rate for Payer: First Health Commercial |
$445.26
|
| Rate for Payer: Humana Commercial |
$398.40
|
| Rate for Payer: Humana KY Medicaid |
$161.19
|
| Rate for Payer: Kentucky WC Medicaid |
$162.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$384.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$345.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$164.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$412.46
|
| Rate for Payer: Ohio Health Group HMO |
$351.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.30
|
| Rate for Payer: PHCS Commercial |
$449.95
|
| Rate for Payer: United Healthcare All Payer |
$412.46
|
|
|
THROMBINAR(THROMBI 5000U/1VIAL
|
Facility
|
IP
|
$468.70
|
|
|
Service Code
|
NDC 338032201
|
| Hospital Charge Code |
25003520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.93 |
| Max. Negotiated Rate |
$449.95 |
| Rate for Payer: Aetna Commercial |
$360.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$365.59
|
| Rate for Payer: Cash Price |
$234.35
|
| Rate for Payer: Cigna Commercial |
$389.02
|
| Rate for Payer: First Health Commercial |
$445.26
|
| Rate for Payer: Humana Commercial |
$398.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$384.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$345.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$140.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$412.46
|
| Rate for Payer: Ohio Health Group HMO |
$351.52
|
| Rate for Payer: Ohio Health Group PPO Differential |
$93.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$145.30
|
| Rate for Payer: PHCS Commercial |
$449.95
|
| Rate for Payer: United Healthcare All Payer |
$412.46
|
|
|
THROMBIN (BOVINE) 20KU SPRAY
|
Facility
|
IP
|
$1,774.36
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25002467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$230.67 |
| Max. Negotiated Rate |
$1,703.39 |
| Rate for Payer: Aetna Commercial |
$1,366.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.00
|
| Rate for Payer: Cash Price |
$887.18
|
| Rate for Payer: Cigna Commercial |
$1,472.72
|
| Rate for Payer: First Health Commercial |
$1,685.64
|
| Rate for Payer: Humana Commercial |
$1,508.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,454.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,561.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,330.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$550.05
|
| Rate for Payer: PHCS Commercial |
$1,703.39
|
| Rate for Payer: United Healthcare All Payer |
$1,561.44
|
|
|
THROMBIN (BOVINE) 20KU SPRAY
|
Facility
|
OP
|
$1,774.36
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25002467
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$230.67 |
| Max. Negotiated Rate |
$1,703.39 |
| Rate for Payer: Aetna Commercial |
$1,366.26
|
| Rate for Payer: Anthem Medicaid |
$610.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.00
|
| Rate for Payer: Cash Price |
$887.18
|
| Rate for Payer: Cigna Commercial |
$1,472.72
|
| Rate for Payer: First Health Commercial |
$1,685.64
|
| Rate for Payer: Humana Commercial |
$1,508.21
|
| Rate for Payer: Humana KY Medicaid |
$610.20
|
| Rate for Payer: Kentucky WC Medicaid |
$616.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,454.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,561.44
|
| Rate for Payer: Ohio Health Group HMO |
$1,330.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$354.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$550.05
|
| Rate for Payer: PHCS Commercial |
$1,703.39
|
| Rate for Payer: United Healthcare All Payer |
$1,561.44
|
|
|
THROMBIN (BOVINE) 20KU VIAL
|
Facility
|
OP
|
$454.46
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25003521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.08 |
| Max. Negotiated Rate |
$436.28 |
| Rate for Payer: Aetna Commercial |
$349.93
|
| Rate for Payer: Anthem Medicaid |
$156.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.48
|
| Rate for Payer: Cash Price |
$227.23
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: First Health Commercial |
$431.74
|
| Rate for Payer: Humana Commercial |
$386.29
|
| Rate for Payer: Humana KY Medicaid |
$156.29
|
| Rate for Payer: Kentucky WC Medicaid |
$157.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$372.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$335.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$159.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$399.92
|
| Rate for Payer: Ohio Health Group HMO |
$340.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.88
|
| Rate for Payer: PHCS Commercial |
$436.28
|
| Rate for Payer: United Healthcare All Payer |
$399.92
|
|
|
THROMBIN (BOVINE) 20KU VIAL
|
Facility
|
IP
|
$454.46
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25003521
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$59.08 |
| Max. Negotiated Rate |
$436.28 |
| Rate for Payer: Aetna Commercial |
$349.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$354.48
|
| Rate for Payer: Cash Price |
$227.23
|
| Rate for Payer: Cigna Commercial |
$377.20
|
| Rate for Payer: First Health Commercial |
$431.74
|
| Rate for Payer: Humana Commercial |
$386.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$372.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$335.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$399.92
|
| Rate for Payer: Ohio Health Group HMO |
$340.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$90.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$59.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$140.88
|
| Rate for Payer: PHCS Commercial |
$436.28
|
| Rate for Payer: United Healthcare All Payer |
$399.92
|
|
|
THROMBIN TIME
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 85670
|
| Hospital Charge Code |
30000629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.77 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem Medicaid |
$22.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$8.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.77
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Humana KY Medicaid |
$22.70
|
| Rate for Payer: Humana Medicare Advantage |
$5.77
|
| Rate for Payer: Kentucky WC Medicaid |
$22.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
THROMBIN TIME
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 85670
|
| Hospital Charge Code |
30000629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$63.36 |
| Rate for Payer: Aetna Commercial |
$50.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cigna Commercial |
$54.78
|
| Rate for Payer: First Health Commercial |
$62.70
|
| Rate for Payer: Humana Commercial |
$56.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.08
|
| Rate for Payer: Ohio Health Group HMO |
$49.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.46
|
| Rate for Payer: PHCS Commercial |
$63.36
|
| Rate for Payer: United Healthcare All Payer |
$58.08
|
|
|
THROMBLYTIC ART/VEN THERAPY
|
Professional
|
Both
|
$6,492.00
|
|
|
Service Code
|
HCPCS 37213
|
| Hospital Charge Code |
76101538
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$202.48 |
| Max. Negotiated Rate |
$6,492.00 |
| Rate for Payer: Anthem Medicaid |
$202.48
|
| Rate for Payer: Buckeye Medicare Advantage |
$6,492.00
|
| Rate for Payer: Cash Price |
$3,246.00
|
| Rate for Payer: Cash Price |
$3,246.00
|
| Rate for Payer: Cigna Commercial |
$467.31
|
| Rate for Payer: Healthspan PPO |
$239.00
|
| Rate for Payer: Humana Medicaid |
$202.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$317.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$206.53
|
| Rate for Payer: Molina Healthcare Passport |
$202.48
|
| Rate for Payer: Multiplan PHCS |
$3,895.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,544.40
|
| Rate for Payer: UHCCP Medicaid |
$2,272.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$204.50
|
|
|
THROMBLYTIC ART/VEN THERAPY
|
Facility
|
OP
|
$6,492.00
|
|
|
Service Code
|
HCPCS 37213
|
| Hospital Charge Code |
76101538
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$843.96 |
| Max. Negotiated Rate |
$6,232.32 |
| Rate for Payer: Aetna Commercial |
$4,998.84
|
| Rate for Payer: Anthem Medicaid |
$2,232.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,063.76
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$3,246.00
|
| Rate for Payer: Cash Price |
$3,246.00
|
| Rate for Payer: Cigna Commercial |
$5,388.36
|
| Rate for Payer: First Health Commercial |
$6,167.40
|
| Rate for Payer: Humana Commercial |
$5,518.20
|
| Rate for Payer: Humana KY Medicaid |
$2,232.60
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$2,255.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,323.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,791.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,277.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,712.96
|
| Rate for Payer: Ohio Health Group HMO |
$4,869.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,298.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$843.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,012.52
|
| Rate for Payer: PHCS Commercial |
$6,232.32
|
| Rate for Payer: United Healthcare All Payer |
$5,712.96
|
|
|
THROMBLYTIC ART/VEN THERAPY
|
Facility
|
IP
|
$6,492.00
|
|
|
Service Code
|
HCPCS 37213
|
| Hospital Charge Code |
76101538
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$843.96 |
| Max. Negotiated Rate |
$6,232.32 |
| Rate for Payer: Aetna Commercial |
$4,998.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,063.76
|
| Rate for Payer: Cash Price |
$3,246.00
|
| Rate for Payer: Cigna Commercial |
$5,388.36
|
| Rate for Payer: First Health Commercial |
$6,167.40
|
| Rate for Payer: Humana Commercial |
$5,518.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,323.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,791.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,947.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,712.96
|
| Rate for Payer: Ohio Health Group HMO |
$4,869.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,298.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$843.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,012.52
|
| Rate for Payer: PHCS Commercial |
$6,232.32
|
| Rate for Payer: United Healthcare All Payer |
$5,712.96
|
|
