|
THRMBC/NFS DIALYSIS CIRCUIT(P
|
Professional
|
Both
|
$580.00
|
|
|
Service Code
|
HCPCS 36904
|
| Hospital Charge Code |
761P1517
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$278.83 |
| Max. Negotiated Rate |
$1,352.98 |
| Rate for Payer: Ambetter Exchange |
$343.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$278.83
|
| Rate for Payer: Anthem Medicaid |
$1,326.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$343.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$343.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$411.60
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$571.18
|
| Rate for Payer: Humana Medicaid |
$1,326.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$443.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$343.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$343.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,352.98
|
| Rate for Payer: Molina Healthcare Passport |
$1,326.45
|
| Rate for Payer: Multiplan PHCS |
$348.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$445.90
|
| Rate for Payer: UHCCP Medicaid |
$292.77
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,339.71
|
| Rate for Payer: Wellcare Medicare Advantage |
$343.00
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT AXI
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35305
|
| Hospital Charge Code |
76101383
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$955.83 |
| Max. Negotiated Rate |
$2,172.16 |
| Rate for Payer: Aetna Commercial |
$2,172.16
|
| Rate for Payer: Ambetter Exchange |
$1,146.99
|
| Rate for Payer: Anthem Medicaid |
$955.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,146.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,146.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,376.39
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,020.81
|
| Rate for Payer: Healthspan PPO |
$2,135.64
|
| Rate for Payer: Humana Medicaid |
$955.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,689.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,146.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,146.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$974.95
|
| Rate for Payer: Molina Healthcare Passport |
$955.83
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,491.09
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,146.99
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT AXI
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35305
|
| Hospital Charge Code |
761P1383
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$955.83 |
| Max. Negotiated Rate |
$2,172.16 |
| Rate for Payer: Aetna Commercial |
$2,172.16
|
| Rate for Payer: Ambetter Exchange |
$1,146.99
|
| Rate for Payer: Anthem Medicaid |
$955.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,146.99
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,146.99
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,376.39
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,020.81
|
| Rate for Payer: Healthspan PPO |
$2,135.64
|
| Rate for Payer: Humana Medicaid |
$955.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,689.65
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,146.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,146.99
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$974.95
|
| Rate for Payer: Molina Healthcare Passport |
$955.83
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,491.09
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,146.99
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT AXI
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35305
|
| Hospital Charge Code |
76101383
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT AXI
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35305
|
| Hospital Charge Code |
76101383
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT ILI
|
Facility
|
IP
|
$2,960.00
|
|
|
Service Code
|
HCPCS 35355
|
| Hospital Charge Code |
76101387
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$888.00 |
| Max. Negotiated Rate |
$2,841.60 |
| Rate for Payer: Aetna Commercial |
$2,279.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,308.80
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cigna Commercial |
$2,456.80
|
| Rate for Payer: First Health Commercial |
$2,812.00
|
| Rate for Payer: Humana Commercial |
$2,516.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,427.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,184.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$888.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,604.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,220.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,575.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.40
|
| Rate for Payer: PHCS Commercial |
$2,841.60
|
| Rate for Payer: United Healthcare All Payer |
$2,604.80
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT ILI
|
Facility
|
OP
|
$2,960.00
|
|
|
Service Code
|
HCPCS 35355
|
| Hospital Charge Code |
76101387
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$888.00 |
| Max. Negotiated Rate |
$2,841.60 |
| Rate for Payer: Aetna Commercial |
$2,279.20
|
| Rate for Payer: Anthem Medicaid |
$1,017.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,308.80
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cigna Commercial |
$2,456.80
|
| Rate for Payer: First Health Commercial |
$2,812.00
|
| Rate for Payer: Humana Commercial |
$2,516.00
|
| Rate for Payer: Humana KY Medicaid |
$1,017.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,028.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,427.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,184.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$888.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,038.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,604.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,220.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,575.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,042.40
|
| Rate for Payer: PHCS Commercial |
$2,841.60
|
| Rate for Payer: United Healthcare All Payer |
$2,604.80
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT ILI
|
Professional
|
Both
|
$2,960.00
|
|
|
Service Code
|
HCPCS 35355
|
| Hospital Charge Code |
76101387
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$929.63 |
| Max. Negotiated Rate |
$1,847.93 |
| Rate for Payer: Aetna Commercial |
$1,847.93
|
| Rate for Payer: Ambetter Exchange |
$964.92
|
| Rate for Payer: Anthem Medicaid |
$929.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$964.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$964.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,157.90
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cigna Commercial |
$1,767.05
|
| Rate for Payer: Healthspan PPO |
$1,816.88
|
| Rate for Payer: Humana Medicaid |
$929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,430.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$964.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$948.22
|
| Rate for Payer: Molina Healthcare Passport |
$929.63
|
| Rate for Payer: Multiplan PHCS |
$1,776.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,254.40
|
| Rate for Payer: UHCCP Medicaid |
$1,036.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$938.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$964.92
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT ILI
|
Professional
|
Both
|
$2,960.00
|
|
|
Service Code
|
HCPCS 35355
|
| Hospital Charge Code |
761P1387
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$929.63 |
| Max. Negotiated Rate |
$1,847.93 |
| Rate for Payer: Aetna Commercial |
$1,847.93
|
| Rate for Payer: Ambetter Exchange |
$964.92
|
| Rate for Payer: Anthem Medicaid |
$929.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$964.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$964.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,157.90
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cash Price |
$1,480.00
|
| Rate for Payer: Cigna Commercial |
$1,767.05
|
| Rate for Payer: Healthspan PPO |
$1,816.88
|
| Rate for Payer: Humana Medicaid |
$929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,430.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$964.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$964.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$948.22
|
| Rate for Payer: Molina Healthcare Passport |
$929.63
|
| Rate for Payer: Multiplan PHCS |
$1,776.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,254.40
|
| Rate for Payer: UHCCP Medicaid |
$1,036.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$938.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$964.92
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT MES
|
Facility
|
IP
|
$3,130.00
|
|
|
Service Code
|
HCPCS 35341
|
| Hospital Charge Code |
76101385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$939.00 |
| Max. Negotiated Rate |
$3,004.80 |
| Rate for Payer: Aetna Commercial |
$2,410.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,441.40
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,597.90
|
| Rate for Payer: First Health Commercial |
$2,973.50
|
| Rate for Payer: Humana Commercial |
$2,660.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,566.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,309.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$939.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,754.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,347.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,723.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,159.70
|
| Rate for Payer: PHCS Commercial |
$3,004.80
|
| Rate for Payer: United Healthcare All Payer |
$2,754.40
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT MES
|
Professional
|
Both
|
$3,130.00
|
|
|
Service Code
|
HCPCS 35341
|
| Hospital Charge Code |
76101385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,095.50 |
| Max. Negotiated Rate |
$2,456.81 |
| Rate for Payer: Aetna Commercial |
$2,456.81
|
| Rate for Payer: Ambetter Exchange |
$1,290.38
|
| Rate for Payer: Anthem Medicaid |
$1,246.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,290.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,290.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,548.46
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,355.16
|
| Rate for Payer: Healthspan PPO |
$2,415.53
|
| Rate for Payer: Humana Medicaid |
$1,246.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,881.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,290.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,271.15
|
| Rate for Payer: Molina Healthcare Passport |
$1,246.23
|
| Rate for Payer: Multiplan PHCS |
$1,878.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,677.49
|
| Rate for Payer: UHCCP Medicaid |
$1,095.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,258.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,290.38
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT MES
|
Professional
|
Both
|
$3,130.00
|
|
|
Service Code
|
HCPCS 35341
|
| Hospital Charge Code |
761P1385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,095.50 |
| Max. Negotiated Rate |
$2,456.81 |
| Rate for Payer: Aetna Commercial |
$2,456.81
|
| Rate for Payer: Ambetter Exchange |
$1,290.38
|
| Rate for Payer: Anthem Medicaid |
$1,246.23
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,290.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,290.38
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,548.46
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,355.16
|
| Rate for Payer: Healthspan PPO |
$2,415.53
|
| Rate for Payer: Humana Medicaid |
$1,246.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,881.24
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,290.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,290.38
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,271.15
|
| Rate for Payer: Molina Healthcare Passport |
$1,246.23
|
| Rate for Payer: Multiplan PHCS |
$1,878.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,677.49
|
| Rate for Payer: UHCCP Medicaid |
$1,095.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,258.69
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,290.38
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT MES
|
Facility
|
OP
|
$3,130.00
|
|
|
Service Code
|
HCPCS 35341
|
| Hospital Charge Code |
76101385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$939.00 |
| Max. Negotiated Rate |
$3,004.80 |
| Rate for Payer: Aetna Commercial |
$2,410.10
|
| Rate for Payer: Anthem Medicaid |
$1,076.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,441.40
|
| Rate for Payer: Cash Price |
$1,565.00
|
| Rate for Payer: Cigna Commercial |
$2,597.90
|
| Rate for Payer: First Health Commercial |
$2,973.50
|
| Rate for Payer: Humana Commercial |
$2,660.50
|
| Rate for Payer: Humana KY Medicaid |
$1,076.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,087.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,566.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,309.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$939.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,098.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,754.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,347.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,504.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,723.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,159.70
|
| Rate for Payer: PHCS Commercial |
$3,004.80
|
| Rate for Payer: United Healthcare All Payer |
$2,754.40
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT POP
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35303
|
| Hospital Charge Code |
761P1381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$955.83 |
| Max. Negotiated Rate |
$2,174.46 |
| Rate for Payer: Aetna Commercial |
$2,174.46
|
| Rate for Payer: Ambetter Exchange |
$1,149.82
|
| Rate for Payer: Anthem Medicaid |
$955.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,149.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,149.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,379.78
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,020.81
|
| Rate for Payer: Healthspan PPO |
$2,137.92
|
| Rate for Payer: Humana Medicaid |
$955.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,693.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,149.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,149.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$974.95
|
| Rate for Payer: Molina Healthcare Passport |
$955.83
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,494.77
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,149.82
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT POP
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35303
|
| Hospital Charge Code |
76101381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$955.83 |
| Max. Negotiated Rate |
$2,174.46 |
| Rate for Payer: Aetna Commercial |
$2,174.46
|
| Rate for Payer: Ambetter Exchange |
$1,149.82
|
| Rate for Payer: Anthem Medicaid |
$955.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,149.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,149.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,379.78
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,020.81
|
| Rate for Payer: Healthspan PPO |
$2,137.92
|
| Rate for Payer: Humana Medicaid |
$955.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,693.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,149.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,149.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$974.95
|
| Rate for Payer: Molina Healthcare Passport |
$955.83
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,494.77
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$965.39
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,149.82
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT POP
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35303
|
| Hospital Charge Code |
76101381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT POP
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35303
|
| Hospital Charge Code |
76101381
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT TIB
|
Professional
|
Both
|
$2,740.00
|
|
|
Service Code
|
HCPCS 35321
|
| Hospital Charge Code |
761P1384
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$738.10 |
| Max. Negotiated Rate |
$1,644.00 |
| Rate for Payer: Aetna Commercial |
$1,573.01
|
| Rate for Payer: Ambetter Exchange |
$850.55
|
| Rate for Payer: Anthem Medicaid |
$738.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$850.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,020.66
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cigna Commercial |
$1,512.95
|
| Rate for Payer: Healthspan PPO |
$1,546.58
|
| Rate for Payer: Humana Medicaid |
$738.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,219.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$850.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$850.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$752.86
|
| Rate for Payer: Molina Healthcare Passport |
$738.10
|
| Rate for Payer: Multiplan PHCS |
$1,644.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,105.71
|
| Rate for Payer: UHCCP Medicaid |
$959.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$745.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$850.55
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT TIB
|
Facility
|
IP
|
$2,740.00
|
|
|
Service Code
|
HCPCS 35321
|
| Hospital Charge Code |
76101384
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$822.00 |
| Max. Negotiated Rate |
$2,630.40 |
| Rate for Payer: Aetna Commercial |
$2,109.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,137.20
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cigna Commercial |
$2,274.20
|
| Rate for Payer: First Health Commercial |
$2,603.00
|
| Rate for Payer: Humana Commercial |
$2,329.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,246.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,022.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$822.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,411.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,055.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,192.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,383.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,890.60
|
| Rate for Payer: PHCS Commercial |
$2,630.40
|
| Rate for Payer: United Healthcare All Payer |
$2,411.20
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT TIB
|
Professional
|
Both
|
$2,740.00
|
|
|
Service Code
|
HCPCS 35321
|
| Hospital Charge Code |
76101384
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$738.10 |
| Max. Negotiated Rate |
$1,644.00 |
| Rate for Payer: Aetna Commercial |
$1,573.01
|
| Rate for Payer: Ambetter Exchange |
$850.55
|
| Rate for Payer: Anthem Medicaid |
$738.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$850.55
|
| Rate for Payer: Buckeye Medicare Advantage |
$850.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,020.66
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cigna Commercial |
$1,512.95
|
| Rate for Payer: Healthspan PPO |
$1,546.58
|
| Rate for Payer: Humana Medicaid |
$738.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,219.47
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$850.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$850.55
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$752.86
|
| Rate for Payer: Molina Healthcare Passport |
$738.10
|
| Rate for Payer: Multiplan PHCS |
$1,644.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,105.71
|
| Rate for Payer: UHCCP Medicaid |
$959.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$745.48
|
| Rate for Payer: Wellcare Medicare Advantage |
$850.55
|
|
|
THRMBNDRTRCTMY W/PATCHGRFT TIB
|
Facility
|
OP
|
$2,740.00
|
|
|
Service Code
|
HCPCS 35321
|
| Hospital Charge Code |
76101384
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$942.29 |
| Max. Negotiated Rate |
$6,992.66 |
| Rate for Payer: Aetna Commercial |
$2,109.80
|
| Rate for Payer: Anthem Medicaid |
$942.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4,994.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,137.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6,992.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$6,742.93
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cash Price |
$1,370.00
|
| Rate for Payer: Cigna Commercial |
$2,274.20
|
| Rate for Payer: First Health Commercial |
$2,603.00
|
| Rate for Payer: Humana Commercial |
$2,329.00
|
| Rate for Payer: Humana KY Medicaid |
$942.29
|
| Rate for Payer: Humana Medicare Advantage |
$4,994.76
|
| Rate for Payer: Kentucky WC Medicaid |
$951.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,246.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,022.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,993.71
|
| Rate for Payer: Molina Healthcare Medicaid |
$961.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,411.20
|
| Rate for Payer: Ohio Health Group HMO |
$2,055.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,192.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,383.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,890.60
|
| Rate for Payer: PHCS Commercial |
$2,630.40
|
| Rate for Payer: United Healthcare All Payer |
$2,411.20
|
|
|
THROMBATE III 1 UN(-500 UNITS)
|
Facility
|
IP
|
$13,514.69
|
|
|
Service Code
|
HCPCS J7197
|
| Hospital Charge Code |
25002479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,054.41 |
| Max. Negotiated Rate |
$12,974.10 |
| Rate for Payer: Aetna Commercial |
$10,406.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,541.46
|
| Rate for Payer: Cash Price |
$6,757.34
|
| Rate for Payer: Cigna Commercial |
$11,217.19
|
| Rate for Payer: First Health Commercial |
$12,838.96
|
| Rate for Payer: Humana Commercial |
$11,487.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,082.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,973.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,054.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,892.93
|
| Rate for Payer: Ohio Health Group HMO |
$10,136.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,811.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,757.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,325.14
|
| Rate for Payer: PHCS Commercial |
$12,974.10
|
| Rate for Payer: United Healthcare All Payer |
$11,892.93
|
|
|
THROMBATE III 1 UN(-500 UNITS)
|
Facility
|
OP
|
$13,514.69
|
|
|
Service Code
|
HCPCS J7197
|
| Hospital Charge Code |
25002479
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.09 |
| Max. Negotiated Rate |
$12,974.10 |
| Rate for Payer: Aetna Commercial |
$10,406.31
|
| Rate for Payer: Anthem Medicaid |
$4,647.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,541.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.52
|
| Rate for Payer: Cash Price |
$6,757.34
|
| Rate for Payer: Cash Price |
$6,757.34
|
| Rate for Payer: Cigna Commercial |
$11,217.19
|
| Rate for Payer: First Health Commercial |
$12,838.96
|
| Rate for Payer: Humana Commercial |
$11,487.49
|
| Rate for Payer: Humana KY Medicaid |
$4,647.70
|
| Rate for Payer: Humana Medicare Advantage |
$4.09
|
| Rate for Payer: Kentucky WC Medicaid |
$4,695.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,082.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,973.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,740.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,892.93
|
| Rate for Payer: Ohio Health Group HMO |
$10,136.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,811.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,757.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,325.14
|
| Rate for Payer: PHCS Commercial |
$12,974.10
|
| Rate for Payer: United Healthcare All Payer |
$11,892.93
|
|
|
THROMB DEV REVISIONS SURGEONS
|
Facility
|
OP
|
$207.00
|
|
| Hospital Charge Code |
76102565
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.10 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$159.39
|
| Rate for Payer: Anthem Medicaid |
$71.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$161.46
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$171.81
|
| Rate for Payer: First Health Commercial |
$196.65
|
| Rate for Payer: Humana Commercial |
$175.95
|
| Rate for Payer: Humana KY Medicaid |
$71.19
|
| Rate for Payer: Kentucky WC Medicaid |
$71.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$169.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$182.16
|
| Rate for Payer: Ohio Health Group HMO |
$155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.83
|
| Rate for Payer: PHCS Commercial |
$198.72
|
| Rate for Payer: United Healthcare All Payer |
$182.16
|
|
|
THROMB DEV REVISIONS SURGEONS
|
Facility
|
IP
|
$207.00
|
|
| Hospital Charge Code |
76102565
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.10 |
| Max. Negotiated Rate |
$198.72 |
| Rate for Payer: Aetna Commercial |
$159.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$161.46
|
| Rate for Payer: Cash Price |
$103.50
|
| Rate for Payer: Cigna Commercial |
$171.81
|
| Rate for Payer: First Health Commercial |
$196.65
|
| Rate for Payer: Humana Commercial |
$175.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$169.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$152.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$182.16
|
| Rate for Payer: Ohio Health Group HMO |
$155.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$165.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$142.83
|
| Rate for Payer: PHCS Commercial |
$198.72
|
| Rate for Payer: United Healthcare All Payer |
$182.16
|
|
