|
UNILAT LT FOLLOWUP PROC W/CAD
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Humana KY Medicaid |
$252.77
|
| Rate for Payer: Kentucky WC Medicaid |
$255.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
UNILAT LT FOLLOWUP PROC W/CAD
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
UNILAT LT FOLLOWUP PROC W/CA(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401P0007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
|
|
UNILAT LT FOLLOWUP PROC W/CA(T
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem Medicaid |
$175.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.80
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Humana KY Medicaid |
$175.39
|
| Rate for Payer: Kentucky WC Medicaid |
$177.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.10
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
UNILAT LT FOLLOWUP PROC W/CA(T
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0007
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.80
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.10
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
UNILAT RT FOLLOWUP PROC W/CAD
|
Facility
|
OP
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem Medicaid |
$252.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Humana KY Medicaid |
$252.77
|
| Rate for Payer: Kentucky WC Medicaid |
$255.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$257.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
UNILAT RT FOLLOWUP PROC W/CAD
|
Professional
|
Both
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$735.00 |
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$735.00
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$441.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$514.50
|
| Rate for Payer: UHCCP Medicaid |
$257.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
|
|
UNILAT RT FOLLOWUP PROC W/CAD
|
Facility
|
IP
|
$735.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$95.55 |
| Max. Negotiated Rate |
$705.60 |
| Rate for Payer: Aetna Commercial |
$565.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$573.30
|
| Rate for Payer: Cash Price |
$367.50
|
| Rate for Payer: Cigna Commercial |
$610.05
|
| Rate for Payer: First Health Commercial |
$698.25
|
| Rate for Payer: Humana Commercial |
$624.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$602.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$542.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$220.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$646.80
|
| Rate for Payer: Ohio Health Group HMO |
$551.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$95.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.85
|
| Rate for Payer: PHCS Commercial |
$705.60
|
| Rate for Payer: United Healthcare All Payer |
$646.80
|
|
|
UNILAT RT FOLLOWUP PROC W/CA(P
|
Professional
|
Both
|
$225.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401P0008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$225.00
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna Commercial |
$210.02
|
| Rate for Payer: Humana Medicaid |
$101.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$47.87
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$135.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$157.50
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
|
|
UNILAT RT FOLLOWUP PROC W/CA(T
|
Facility
|
IP
|
$510.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.80
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.10
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
UNILAT RT FOLLOWUP PROC W/CA(T
|
Facility
|
OP
|
$510.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna Commercial |
$392.70
|
| Rate for Payer: Anthem Medicaid |
$175.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$397.80
|
| Rate for Payer: Cash Price |
$255.00
|
| Rate for Payer: Cigna Commercial |
$423.30
|
| Rate for Payer: First Health Commercial |
$484.50
|
| Rate for Payer: Humana Commercial |
$433.50
|
| Rate for Payer: Humana KY Medicaid |
$175.39
|
| Rate for Payer: Kentucky WC Medicaid |
$177.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$178.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$448.80
|
| Rate for Payer: Ohio Health Group HMO |
$382.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.10
|
| Rate for Payer: PHCS Commercial |
$489.60
|
| Rate for Payer: United Healthcare All Payer |
$448.80
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +0
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem Medicaid |
$623.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Humana KY Medicaid |
$623.15
|
| Rate for Payer: Kentucky WC Medicaid |
$629.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +0
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE+12
|
Facility
|
OP
|
$1,896.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.48 |
| Max. Negotiated Rate |
$1,820.16 |
| Rate for Payer: Aetna Commercial |
$1,459.92
|
| Rate for Payer: Anthem Medicaid |
$652.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.88
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cigna Commercial |
$1,573.68
|
| Rate for Payer: First Health Commercial |
$1,801.20
|
| Rate for Payer: Humana Commercial |
$1,611.60
|
| Rate for Payer: Humana KY Medicaid |
$652.03
|
| Rate for Payer: Kentucky WC Medicaid |
$658.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,399.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$665.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,668.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,422.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.76
|
| Rate for Payer: PHCS Commercial |
$1,820.16
|
| Rate for Payer: United Healthcare All Payer |
$1,668.48
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE+12
|
Facility
|
IP
|
$1,896.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.48 |
| Max. Negotiated Rate |
$1,820.16 |
| Rate for Payer: Aetna Commercial |
$1,459.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.88
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cigna Commercial |
$1,573.68
|
| Rate for Payer: First Health Commercial |
$1,801.20
|
| Rate for Payer: Humana Commercial |
$1,611.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,399.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,668.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,422.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.76
|
| Rate for Payer: PHCS Commercial |
$1,820.16
|
| Rate for Payer: United Healthcare All Payer |
$1,668.48
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE -3
|
Facility
|
IP
|
$1,896.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.48 |
| Max. Negotiated Rate |
$1,820.16 |
| Rate for Payer: Aetna Commercial |
$1,459.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.88
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cigna Commercial |
$1,573.68
|
| Rate for Payer: First Health Commercial |
$1,801.20
|
| Rate for Payer: Humana Commercial |
$1,611.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,399.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,668.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,422.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.76
|
| Rate for Payer: PHCS Commercial |
$1,820.16
|
| Rate for Payer: United Healthcare All Payer |
$1,668.48
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE -3
|
Facility
|
OP
|
$1,896.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$246.48 |
| Max. Negotiated Rate |
$1,820.16 |
| Rate for Payer: Aetna Commercial |
$1,459.92
|
| Rate for Payer: Anthem Medicaid |
$652.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,478.88
|
| Rate for Payer: Cash Price |
$948.00
|
| Rate for Payer: Cigna Commercial |
$1,573.68
|
| Rate for Payer: First Health Commercial |
$1,801.20
|
| Rate for Payer: Humana Commercial |
$1,611.60
|
| Rate for Payer: Humana KY Medicaid |
$652.03
|
| Rate for Payer: Kentucky WC Medicaid |
$658.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,554.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,399.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$568.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$665.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,668.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,422.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$379.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$246.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$587.76
|
| Rate for Payer: PHCS Commercial |
$1,820.16
|
| Rate for Payer: United Healthcare All Payer |
$1,668.48
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +4
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +4
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem Medicaid |
$623.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Humana KY Medicaid |
$623.15
|
| Rate for Payer: Kentucky WC Medicaid |
$629.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +8
|
Facility
|
IP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +8
|
Facility
|
OP
|
$1,812.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$235.56 |
| Max. Negotiated Rate |
$1,739.52 |
| Rate for Payer: Aetna Commercial |
$1,395.24
|
| Rate for Payer: Anthem Medicaid |
$623.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,413.36
|
| Rate for Payer: Cash Price |
$906.00
|
| Rate for Payer: Cigna Commercial |
$1,503.96
|
| Rate for Payer: First Health Commercial |
$1,721.40
|
| Rate for Payer: Humana Commercial |
$1,540.20
|
| Rate for Payer: Humana KY Medicaid |
$623.15
|
| Rate for Payer: Kentucky WC Medicaid |
$629.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,485.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,337.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$543.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$635.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,594.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,359.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$235.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$561.72
|
| Rate for Payer: PHCS Commercial |
$1,739.52
|
| Rate for Payer: United Healthcare All Payer |
$1,594.56
|
|
|
UNISOM SLEEP AID 25MG TABLET
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
25001628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna Commercial |
$0.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.16
|
| Rate for Payer: First Health Commercial |
$0.18
|
| Rate for Payer: Humana Commercial |
$0.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.17
|
| Rate for Payer: Ohio Health Group HMO |
$0.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Payer |
$0.17
|
|
|
UNISOM SLEEP AID 25MG TABLET
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
25001628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna Commercial |
$0.15
|
| Rate for Payer: Anthem Medicaid |
$0.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna Commercial |
$0.16
|
| Rate for Payer: First Health Commercial |
$0.18
|
| Rate for Payer: Humana Commercial |
$0.16
|
| Rate for Payer: Humana KY Medicaid |
$0.07
|
| Rate for Payer: Kentucky WC Medicaid |
$0.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.17
|
| Rate for Payer: Ohio Health Group HMO |
$0.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.06
|
| Rate for Payer: PHCS Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Payer |
$0.17
|
|
|
UNITRAX ENDO HEAD 42MM
|
Facility
|
OP
|
$6,705.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$871.72 |
| Max. Negotiated Rate |
$6,437.28 |
| Rate for Payer: Aetna Commercial |
$5,163.24
|
| Rate for Payer: Anthem Medicaid |
$2,306.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,230.29
|
| Rate for Payer: Cash Price |
$3,352.75
|
| Rate for Payer: Cigna Commercial |
$5,565.56
|
| Rate for Payer: First Health Commercial |
$6,370.22
|
| Rate for Payer: Humana Commercial |
$5,699.68
|
| Rate for Payer: Humana KY Medicaid |
$2,306.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,329.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,498.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,352.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,029.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,341.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$871.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,078.70
|
| Rate for Payer: PHCS Commercial |
$6,437.28
|
| Rate for Payer: United Healthcare All Payer |
$5,900.84
|
|
|
UNITRAX ENDO HEAD 42MM
|
Facility
|
IP
|
$6,705.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$871.72 |
| Max. Negotiated Rate |
$6,437.28 |
| Rate for Payer: Aetna Commercial |
$5,163.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,230.29
|
| Rate for Payer: Cash Price |
$3,352.75
|
| Rate for Payer: Cigna Commercial |
$5,565.56
|
| Rate for Payer: First Health Commercial |
$6,370.22
|
| Rate for Payer: Humana Commercial |
$5,699.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,498.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,948.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,011.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,900.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,029.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,341.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$871.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,078.70
|
| Rate for Payer: PHCS Commercial |
$6,437.28
|
| Rate for Payer: United Healthcare All Payer |
$5,900.84
|
|
