|
ULTIMA UNIPOLAR HEAD 63MM
|
Facility
|
IP
|
$3,518.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,055.62 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna Commercial |
$2,709.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,744.62
|
| Rate for Payer: Cash Price |
$1,759.38
|
| Rate for Payer: Cigna Commercial |
$2,920.56
|
| Rate for Payer: First Health Commercial |
$3,342.81
|
| Rate for Payer: Humana Commercial |
$2,990.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,885.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,596.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,055.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,096.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,639.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,815.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,061.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,427.94
|
| Rate for Payer: PHCS Commercial |
$3,378.00
|
| Rate for Payer: United Healthcare All Payer |
$3,096.50
|
|
|
ULTIMA UNIPOLAR SLEEVE 0MM
|
Facility
|
IP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE 0MM
|
Facility
|
OP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem Medicaid |
$1,013.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Humana KY Medicaid |
$1,013.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE 10MM
|
Facility
|
OP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem Medicaid |
$1,013.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Humana KY Medicaid |
$1,013.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE 10MM
|
Facility
|
IP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE -3MM
|
Facility
|
IP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE -3MM
|
Facility
|
OP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem Medicaid |
$1,013.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Humana KY Medicaid |
$1,013.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE 5MM
|
Facility
|
IP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLAR SLEEVE 5MM
|
Facility
|
OP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem Medicaid |
$1,013.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Humana KY Medicaid |
$1,013.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLR ADAP SLEEV 12MM
|
Facility
|
IP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIMA UNIPOLR ADAP SLEEV 12MM
|
Facility
|
OP
|
$2,948.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.41 |
| Max. Negotiated Rate |
$2,830.12 |
| Rate for Payer: Aetna Commercial |
$2,269.99
|
| Rate for Payer: Anthem Medicaid |
$1,013.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,299.47
|
| Rate for Payer: Cash Price |
$1,474.02
|
| Rate for Payer: Cigna Commercial |
$2,446.87
|
| Rate for Payer: First Health Commercial |
$2,800.64
|
| Rate for Payer: Humana Commercial |
$2,505.83
|
| Rate for Payer: Humana KY Medicaid |
$1,013.83
|
| Rate for Payer: Kentucky WC Medicaid |
$1,024.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,417.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,175.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$884.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,034.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,594.28
|
| Rate for Payer: Ohio Health Group HMO |
$2,211.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,358.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,564.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,034.15
|
| Rate for Payer: PHCS Commercial |
$2,830.12
|
| Rate for Payer: United Healthcare All Payer |
$2,594.28
|
|
|
ULTIVA 1000MCG
|
Facility
|
IP
|
$148.55
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$142.61 |
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.87
|
| Rate for Payer: Cash Price |
$74.28
|
| Rate for Payer: Cigna Commercial |
$123.30
|
| Rate for Payer: First Health Commercial |
$141.12
|
| Rate for Payer: Humana Commercial |
$126.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.72
|
| Rate for Payer: Ohio Health Group HMO |
$111.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.50
|
| Rate for Payer: PHCS Commercial |
$142.61
|
| Rate for Payer: United Healthcare All Payer |
$130.72
|
|
|
ULTIVA 1000MCG
|
Facility
|
OP
|
$148.55
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$142.61 |
| Rate for Payer: Aetna Commercial |
$114.38
|
| Rate for Payer: Anthem Medicaid |
$51.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$115.87
|
| Rate for Payer: Cash Price |
$74.28
|
| Rate for Payer: Cigna Commercial |
$123.30
|
| Rate for Payer: First Health Commercial |
$141.12
|
| Rate for Payer: Humana Commercial |
$126.27
|
| Rate for Payer: Humana KY Medicaid |
$51.09
|
| Rate for Payer: Kentucky WC Medicaid |
$51.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$121.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$109.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$52.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$130.72
|
| Rate for Payer: Ohio Health Group HMO |
$111.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$118.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$129.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$102.50
|
| Rate for Payer: PHCS Commercial |
$142.61
|
| Rate for Payer: United Healthcare All Payer |
$130.72
|
|
|
ULTIVA 1,000MCG/100ML ANE
|
Facility
|
IP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004217
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.01
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 1,000MCG/100ML ANE
|
Facility
|
OP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004217
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem Medicaid |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Humana KY Medicaid |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$47.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.01
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 1,000MCG/50ML ANE
|
Facility
|
IP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004216
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.01
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 1,000MCG/50ML ANE
|
Facility
|
OP
|
$136.25
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004216
|
|
Hospital Revenue Code
|
890
|
| Min. Negotiated Rate |
$40.88 |
| Max. Negotiated Rate |
$130.80 |
| Rate for Payer: Aetna Commercial |
$104.91
|
| Rate for Payer: Anthem Medicaid |
$46.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$106.28
|
| Rate for Payer: Cash Price |
$68.12
|
| Rate for Payer: Cigna Commercial |
$113.09
|
| Rate for Payer: First Health Commercial |
$129.44
|
| Rate for Payer: Humana Commercial |
$115.81
|
| Rate for Payer: Humana KY Medicaid |
$46.86
|
| Rate for Payer: Kentucky WC Medicaid |
$47.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$111.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$100.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$40.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$47.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$119.90
|
| Rate for Payer: Ohio Health Group HMO |
$102.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$118.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$94.01
|
| Rate for Payer: PHCS Commercial |
$130.80
|
| Rate for Payer: United Healthcare All Payer |
$119.90
|
|
|
ULTIVA 9REMIFENTANIL 1MG/3ML
|
Facility
|
IP
|
$330.25
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.08 |
| Max. Negotiated Rate |
$317.04 |
| Rate for Payer: Aetna Commercial |
$254.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.60
|
| Rate for Payer: Cash Price |
$165.12
|
| Rate for Payer: Cigna Commercial |
$274.11
|
| Rate for Payer: First Health Commercial |
$313.74
|
| Rate for Payer: Humana Commercial |
$280.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.62
|
| Rate for Payer: Ohio Health Group HMO |
$247.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$264.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.87
|
| Rate for Payer: PHCS Commercial |
$317.04
|
| Rate for Payer: United Healthcare All Payer |
$290.62
|
|
|
ULTIVA 9REMIFENTANIL 1MG/3ML
|
Facility
|
OP
|
$330.25
|
|
|
Service Code
|
NDC 143939101
|
| Hospital Charge Code |
25003550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.08 |
| Max. Negotiated Rate |
$317.04 |
| Rate for Payer: Aetna Commercial |
$254.29
|
| Rate for Payer: Anthem Medicaid |
$113.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$257.60
|
| Rate for Payer: Cash Price |
$165.12
|
| Rate for Payer: Cigna Commercial |
$274.11
|
| Rate for Payer: First Health Commercial |
$313.74
|
| Rate for Payer: Humana Commercial |
$280.71
|
| Rate for Payer: Humana KY Medicaid |
$113.57
|
| Rate for Payer: Kentucky WC Medicaid |
$114.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$270.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$243.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$115.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$290.62
|
| Rate for Payer: Ohio Health Group HMO |
$247.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$264.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$287.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$227.87
|
| Rate for Payer: PHCS Commercial |
$317.04
|
| Rate for Payer: United Healthcare All Payer |
$290.62
|
|
|
ULTRA CATH. 5FR 100CM
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
ULTRA CATH. 5FR 100CM
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS C1751
|
| Hospital Charge Code |
27000040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.93
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
ULTRAM (TRAMADOL HCL 50MG/1TAB
|
Facility
|
IP
|
$60.08
|
|
|
Service Code
|
NDC 51079099120
|
| Hospital Charge Code |
25001624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$57.68 |
| Rate for Payer: Aetna Commercial |
$46.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.86
|
| Rate for Payer: Cash Price |
$30.04
|
| Rate for Payer: Cigna Commercial |
$49.87
|
| Rate for Payer: First Health Commercial |
$57.08
|
| Rate for Payer: Humana Commercial |
$51.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.87
|
| Rate for Payer: Ohio Health Group HMO |
$45.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.46
|
| Rate for Payer: PHCS Commercial |
$57.68
|
| Rate for Payer: United Healthcare All Payer |
$52.87
|
|
|
ULTRAM (TRAMADOL HCL 50MG/1TAB
|
Facility
|
OP
|
$60.08
|
|
|
Service Code
|
NDC 51079099120
|
| Hospital Charge Code |
25001624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.02 |
| Max. Negotiated Rate |
$57.68 |
| Rate for Payer: Aetna Commercial |
$46.26
|
| Rate for Payer: Anthem Medicaid |
$20.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.86
|
| Rate for Payer: Cash Price |
$30.04
|
| Rate for Payer: Cigna Commercial |
$49.87
|
| Rate for Payer: First Health Commercial |
$57.08
|
| Rate for Payer: Humana Commercial |
$51.07
|
| Rate for Payer: Humana KY Medicaid |
$20.66
|
| Rate for Payer: Kentucky WC Medicaid |
$20.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.87
|
| Rate for Payer: Ohio Health Group HMO |
$45.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.46
|
| Rate for Payer: PHCS Commercial |
$57.68
|
| Rate for Payer: United Healthcare All Payer |
$52.87
|
|
|
ULTRASONIC GUIDANCE
|
Professional
|
Both
|
$1,076.00
|
|
|
Service Code
|
HCPCS 76932
|
| Hospital Charge Code |
40200065
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$44.93 |
| Max. Negotiated Rate |
$753.20 |
| Rate for Payer: Aetna Commercial |
$150.88
|
| Rate for Payer: Anthem Medicaid |
$70.51
|
| Rate for Payer: Cash Price |
$538.00
|
| Rate for Payer: Cash Price |
$538.00
|
| Rate for Payer: Cigna Commercial |
$143.10
|
| Rate for Payer: Healthspan PPO |
$235.16
|
| Rate for Payer: Humana Medicaid |
$70.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.93
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$71.92
|
| Rate for Payer: Molina Healthcare Passport |
$70.51
|
| Rate for Payer: Multiplan PHCS |
$645.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$753.20
|
| Rate for Payer: UHCCP Medicaid |
$376.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.22
|
|
|
ULTRASONIC GUIDANCE
|
Facility
|
OP
|
$1,076.00
|
|
|
Service Code
|
HCPCS 76932
|
| Hospital Charge Code |
40200065
|
|
Hospital Revenue Code
|
402
|
| Min. Negotiated Rate |
$322.80 |
| Max. Negotiated Rate |
$1,032.96 |
| Rate for Payer: Aetna Commercial |
$828.52
|
| Rate for Payer: Anthem Medicaid |
$370.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$839.28
|
| Rate for Payer: Cash Price |
$538.00
|
| Rate for Payer: Cigna Commercial |
$893.08
|
| Rate for Payer: First Health Commercial |
$1,022.20
|
| Rate for Payer: Humana Commercial |
$914.60
|
| Rate for Payer: Humana KY Medicaid |
$370.04
|
| Rate for Payer: Kentucky WC Medicaid |
$373.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$882.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$794.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$322.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$377.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$946.88
|
| Rate for Payer: Ohio Health Group HMO |
$807.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$860.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$936.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$742.44
|
| Rate for Payer: PHCS Commercial |
$1,032.96
|
| Rate for Payer: United Healthcare All Payer |
$946.88
|
|
