|
UNILAT RT FOLLOWUP PROC W/CAD
|
Professional
|
Both
|
$753.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$47.87 |
| Max. Negotiated Rate |
$451.80 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cash Price |
$376.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.13
|
| Rate for Payer: Molina Healthcare Passport |
$101.11
|
| Rate for Payer: Multiplan PHCS |
$451.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$263.55
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILAT RT FOLLOWUP PROC W/CAD
|
Facility
|
OP
|
$753.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
40100008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$225.90 |
| Max. Negotiated Rate |
$722.88 |
| Rate for Payer: Aetna Commercial |
$579.81
|
| Rate for Payer: Anthem Medicaid |
$258.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$587.34
|
| Rate for Payer: Cash Price |
$376.50
|
| Rate for Payer: Cigna Commercial |
$624.99
|
| Rate for Payer: First Health Commercial |
$715.35
|
| Rate for Payer: Humana Commercial |
$640.05
|
| Rate for Payer: Humana KY Medicaid |
$258.96
|
| Rate for Payer: Kentucky WC Medicaid |
$261.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$617.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$555.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$264.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$662.64
|
| Rate for Payer: Ohio Health Group HMO |
$564.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$602.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$655.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$519.57
|
| Rate for Payer: PHCS Commercial |
$722.88
|
| Rate for Payer: United Healthcare All Payer |
$662.64
|
|
|
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 |
$210.02 |
| Rate for Payer: Ambetter Exchange |
$113.66
|
| Rate for Payer: Anthem Medicaid |
$101.11
|
| Rate for Payer: Buckeye Individual/Medicaid |
$113.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$113.66
|
| Rate for Payer: CareSource Just4Me Medicare |
$136.39
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$113.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$113.66
|
| 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 |
$147.76
|
| Rate for Payer: UHCCP Medicaid |
$78.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.12
|
| Rate for Payer: Wellcare Medicare Advantage |
$113.66
|
|
|
UNILAT RT FOLLOWUP PROC W/CA(T
|
Facility
|
IP
|
$528.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$506.88 |
| Rate for Payer: Aetna Commercial |
$406.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$438.24
|
| Rate for Payer: First Health Commercial |
$501.60
|
| Rate for Payer: Humana Commercial |
$448.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
| Rate for Payer: Ohio Health Group HMO |
$396.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| Rate for Payer: PHCS Commercial |
$506.88
|
| Rate for Payer: United Healthcare All Payer |
$464.64
|
|
|
UNILAT RT FOLLOWUP PROC W/CA(T
|
Facility
|
OP
|
$528.00
|
|
|
Service Code
|
HCPCS 77065
|
| Hospital Charge Code |
401T0008
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$506.88 |
| Rate for Payer: Aetna Commercial |
$406.56
|
| Rate for Payer: Anthem Medicaid |
$181.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.84
|
| Rate for Payer: Cash Price |
$264.00
|
| Rate for Payer: Cigna Commercial |
$438.24
|
| Rate for Payer: First Health Commercial |
$501.60
|
| Rate for Payer: Humana Commercial |
$448.80
|
| Rate for Payer: Humana KY Medicaid |
$181.58
|
| Rate for Payer: Kentucky WC Medicaid |
$183.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$185.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$464.64
|
| Rate for Payer: Ohio Health Group HMO |
$396.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$422.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$459.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$364.32
|
| Rate for Payer: PHCS Commercial |
$506.88
|
| Rate for Payer: United Healthcare All Payer |
$464.64
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +0
|
Facility
|
IP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +0
|
Facility
|
OP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem Medicaid |
$619.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Humana KY Medicaid |
$619.57
|
| Rate for Payer: Kentucky WC Medicaid |
$625.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$632.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE+12
|
Facility
|
OP
|
$1,892.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$567.84 |
| Max. Negotiated Rate |
$1,817.09 |
| Rate for Payer: Aetna Commercial |
$1,457.46
|
| Rate for Payer: Anthem Medicaid |
$650.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.38
|
| Rate for Payer: Cash Price |
$946.40
|
| Rate for Payer: Cigna Commercial |
$1,571.02
|
| Rate for Payer: First Health Commercial |
$1,798.16
|
| Rate for Payer: Humana Commercial |
$1,608.88
|
| Rate for Payer: Humana KY Medicaid |
$650.93
|
| Rate for Payer: Kentucky WC Medicaid |
$657.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,552.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,514.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,646.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,306.03
|
| Rate for Payer: PHCS Commercial |
$1,817.09
|
| Rate for Payer: United Healthcare All Payer |
$1,665.66
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE+12
|
Facility
|
IP
|
$1,892.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$567.84 |
| Max. Negotiated Rate |
$1,817.09 |
| Rate for Payer: Aetna Commercial |
$1,457.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.38
|
| Rate for Payer: Cash Price |
$946.40
|
| Rate for Payer: Cigna Commercial |
$1,571.02
|
| Rate for Payer: First Health Commercial |
$1,798.16
|
| Rate for Payer: Humana Commercial |
$1,608.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,552.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,514.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,646.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,306.03
|
| Rate for Payer: PHCS Commercial |
$1,817.09
|
| Rate for Payer: United Healthcare All Payer |
$1,665.66
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE -3
|
Facility
|
OP
|
$1,892.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$567.84 |
| Max. Negotiated Rate |
$1,817.09 |
| Rate for Payer: Aetna Commercial |
$1,457.46
|
| Rate for Payer: Anthem Medicaid |
$650.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.38
|
| Rate for Payer: Cash Price |
$946.40
|
| Rate for Payer: Cigna Commercial |
$1,571.02
|
| Rate for Payer: First Health Commercial |
$1,798.16
|
| Rate for Payer: Humana Commercial |
$1,608.88
|
| Rate for Payer: Humana KY Medicaid |
$650.93
|
| Rate for Payer: Kentucky WC Medicaid |
$657.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,552.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.84
|
| Rate for Payer: Molina Healthcare Medicaid |
$663.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,514.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,646.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,306.03
|
| Rate for Payer: PHCS Commercial |
$1,817.09
|
| Rate for Payer: United Healthcare All Payer |
$1,665.66
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE -3
|
Facility
|
IP
|
$1,892.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$567.84 |
| Max. Negotiated Rate |
$1,817.09 |
| Rate for Payer: Aetna Commercial |
$1,457.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,476.38
|
| Rate for Payer: Cash Price |
$946.40
|
| Rate for Payer: Cigna Commercial |
$1,571.02
|
| Rate for Payer: First Health Commercial |
$1,798.16
|
| Rate for Payer: Humana Commercial |
$1,608.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,552.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,396.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$567.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,665.66
|
| Rate for Payer: Ohio Health Group HMO |
$1,419.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,514.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,646.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,306.03
|
| Rate for Payer: PHCS Commercial |
$1,817.09
|
| Rate for Payer: United Healthcare All Payer |
$1,665.66
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +4
|
Facility
|
OP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem Medicaid |
$619.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Humana KY Medicaid |
$619.57
|
| Rate for Payer: Kentucky WC Medicaid |
$625.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$632.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +4
|
Facility
|
IP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +8
|
Facility
|
IP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
UNIPOLAR 12/14 TAPER SLEEVE +8
|
Facility
|
OP
|
$1,801.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$540.48 |
| Max. Negotiated Rate |
$1,729.54 |
| Rate for Payer: Aetna Commercial |
$1,387.23
|
| Rate for Payer: Anthem Medicaid |
$619.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.25
|
| Rate for Payer: Cash Price |
$900.80
|
| Rate for Payer: Cigna Commercial |
$1,495.33
|
| Rate for Payer: First Health Commercial |
$1,711.52
|
| Rate for Payer: Humana Commercial |
$1,531.36
|
| Rate for Payer: Humana KY Medicaid |
$619.57
|
| Rate for Payer: Kentucky WC Medicaid |
$625.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$632.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.41
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,441.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,567.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,243.10
|
| Rate for Payer: PHCS Commercial |
$1,729.54
|
| Rate for Payer: United Healthcare All Payer |
$1,585.41
|
|
|
UNISOM SLEEP AID 25MG TABLET
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
25001628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| 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 |
$0.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.13
|
| Rate for Payer: PHCS Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Payer |
$0.17
|
|
|
UNISOM SLEEP AID 25MG TABLET
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
25001628
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.06 |
| 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 |
$0.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.13
|
| Rate for Payer: PHCS Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Payer |
$0.17
|
|
|
UNITRAX ENDO HEAD 42MM
|
Facility
|
OP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem Medicaid |
$2,374.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Humana KY Medicaid |
$2,374.80
|
| Rate for Payer: Kentucky WC Medicaid |
$2,398.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 42MM
|
Facility
|
IP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 43MM
|
Facility
|
OP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem Medicaid |
$2,374.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Humana KY Medicaid |
$2,374.80
|
| Rate for Payer: Kentucky WC Medicaid |
$2,398.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 43MM
|
Facility
|
IP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 44MM
|
Facility
|
OP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem Medicaid |
$2,374.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Humana KY Medicaid |
$2,374.80
|
| Rate for Payer: Kentucky WC Medicaid |
$2,398.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 44MM
|
Facility
|
IP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 45MM
|
Facility
|
IP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
|
UNITRAX ENDO HEAD 45MM
|
Facility
|
OP
|
$6,905.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,071.65 |
| Max. Negotiated Rate |
$6,629.28 |
| Rate for Payer: Aetna Commercial |
$5,317.23
|
| Rate for Payer: Anthem Medicaid |
$2,374.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.29
|
| Rate for Payer: Cash Price |
$3,452.75
|
| Rate for Payer: Cigna Commercial |
$5,731.56
|
| Rate for Payer: First Health Commercial |
$6,560.23
|
| Rate for Payer: Humana Commercial |
$5,869.68
|
| Rate for Payer: Humana KY Medicaid |
$2,374.80
|
| Rate for Payer: Kentucky WC Medicaid |
$2,398.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,662.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,076.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,524.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,007.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,764.80
|
| Rate for Payer: PHCS Commercial |
$6,629.28
|
| Rate for Payer: United Healthcare All Payer |
$6,076.84
|
|
