|
VISION BLUE
|
Facility
|
IP
|
$349.10
|
|
|
Service Code
|
NDC 68803061210
|
| Hospital Charge Code |
25003577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$45.38 |
| Max. Negotiated Rate |
$335.14 |
| Rate for Payer: Aetna Commercial |
$268.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$272.30
|
| Rate for Payer: Cash Price |
$174.55
|
| Rate for Payer: Cigna Commercial |
$289.75
|
| Rate for Payer: First Health Commercial |
$331.64
|
| Rate for Payer: Humana Commercial |
$296.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$286.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$257.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$104.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$307.21
|
| Rate for Payer: Ohio Health Group HMO |
$261.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$45.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$108.22
|
| Rate for Payer: PHCS Commercial |
$335.14
|
| Rate for Payer: United Healthcare All Payer |
$307.21
|
|
|
VISION PV 8.2 10MHZ
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
VISION PV 8.2 10MHZ
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
VISION SCREEN
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
51000058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.40
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
VISION SCREEN
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
51000058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$8.07
|
| Rate for Payer: Anthem Medicaid |
$15.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$25.52
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$15.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$15.95
|
| Rate for Payer: Molina Healthcare Passport |
$15.64
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$8.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.80
|
|
|
VISION SCREEN
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
51000058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$5.20 |
| Max. Negotiated Rate |
$38.40 |
| Rate for Payer: Aetna Commercial |
$30.80
|
| Rate for Payer: Anthem Medicaid |
$13.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$31.20
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$33.20
|
| Rate for Payer: First Health Commercial |
$38.00
|
| Rate for Payer: Humana Commercial |
$34.00
|
| Rate for Payer: Humana KY Medicaid |
$13.76
|
| Rate for Payer: Kentucky WC Medicaid |
$13.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$32.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$29.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$14.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$35.20
|
| Rate for Payer: Ohio Health Group HMO |
$30.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.40
|
| Rate for Payer: PHCS Commercial |
$38.40
|
| Rate for Payer: United Healthcare All Payer |
$35.20
|
|
|
VISION SCREEN(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 99172
|
| Hospital Charge Code |
510P0058
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$8.07
|
| Rate for Payer: Anthem Medicaid |
$15.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$25.52
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$15.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$15.95
|
| Rate for Payer: Molina Healthcare Passport |
$15.64
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$8.47
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$15.80
|
|
|
VISIONS PV .014P DIG IVUS CATH
|
Facility
|
IP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
VISIONS PV .014P DIG IVUS CATH
|
Facility
|
OP
|
$4,912.50
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$638.62 |
| Max. Negotiated Rate |
$4,716.00 |
| Rate for Payer: Aetna Commercial |
$3,782.62
|
| Rate for Payer: Anthem Medicaid |
$1,689.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,831.75
|
| Rate for Payer: Cash Price |
$2,456.25
|
| Rate for Payer: Cigna Commercial |
$4,077.38
|
| Rate for Payer: First Health Commercial |
$4,666.88
|
| Rate for Payer: Humana Commercial |
$4,175.62
|
| Rate for Payer: Humana KY Medicaid |
$1,689.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,706.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,028.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,625.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,473.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,723.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,323.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,684.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$982.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$638.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,522.88
|
| Rate for Payer: PHCS Commercial |
$4,716.00
|
| Rate for Payer: United Healthcare All Payer |
$4,323.00
|
|
|
VISIONS PV .035 DIG. IVUS CATH
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
VISIONS PV .035 DIG. IVUS CATH
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1753
|
| Hospital Charge Code |
27000042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
VISIPAQUE 270 1mL (150mL SDV)
|
Facility
|
OP
|
$716.54
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
25004284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.15 |
| Max. Negotiated Rate |
$687.88 |
| Rate for Payer: Aetna Commercial |
$551.74
|
| Rate for Payer: Anthem Medicaid |
$246.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$558.90
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cigna Commercial |
$594.73
|
| Rate for Payer: First Health Commercial |
$680.71
|
| Rate for Payer: Humana Commercial |
$609.06
|
| Rate for Payer: Humana KY Medicaid |
$246.42
|
| Rate for Payer: Kentucky WC Medicaid |
$248.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$587.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$528.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$214.96
|
| Rate for Payer: Molina Healthcare Medicaid |
$251.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$630.56
|
| Rate for Payer: Ohio Health Group HMO |
$537.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.13
|
| Rate for Payer: PHCS Commercial |
$687.88
|
| Rate for Payer: United Healthcare All Payer |
$630.56
|
|
|
VISIPAQUE 270 1mL (150mL SDV)
|
Facility
|
IP
|
$716.54
|
|
|
Service Code
|
HCPCS Q9966
|
| Hospital Charge Code |
25004284
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$93.15 |
| Max. Negotiated Rate |
$687.88 |
| Rate for Payer: Aetna Commercial |
$551.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$558.90
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cigna Commercial |
$594.73
|
| Rate for Payer: First Health Commercial |
$680.71
|
| Rate for Payer: Humana Commercial |
$609.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$587.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$528.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$214.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$630.56
|
| Rate for Payer: Ohio Health Group HMO |
$537.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$143.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$222.13
|
| Rate for Payer: PHCS Commercial |
$687.88
|
| Rate for Payer: United Healthcare All Payer |
$630.56
|
|
|
VISIPAQUE 320 1mL (100mL SDV)
|
Facility
|
IP
|
$490.93
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.82 |
| Max. Negotiated Rate |
$471.29 |
| Rate for Payer: Aetna Commercial |
$378.02
|
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Cash Price |
$245.46
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$407.47
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: First Health Commercial |
$466.38
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana Commercial |
$417.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$402.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$362.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Group HMO |
$368.20
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.19
|
| Rate for Payer: PHCS Commercial |
$471.29
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Payer |
$432.02
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
|
|
VISIPAQUE 320 1mL (100mL SDV)
|
Facility
|
OP
|
$490.93
|
|
|
Service Code
|
HCPCS Q9967
|
| Hospital Charge Code |
25003578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.82 |
| Max. Negotiated Rate |
$471.29 |
| Rate for Payer: Aetna Commercial |
$378.02
|
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Anthem Medicaid |
$168.83
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$382.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Cash Price |
$245.46
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: Cigna Commercial |
$407.47
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: First Health Commercial |
$466.38
|
| Rate for Payer: Humana Commercial |
$417.29
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana KY Medicaid |
$168.83
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Kentucky WC Medicaid |
$170.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$402.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$362.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$172.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$432.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Group HMO |
$368.20
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$63.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$152.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: PHCS Commercial |
$471.29
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
| Rate for Payer: United Healthcare All Payer |
$432.02
|
|
|
VISIPORT PLUS 5MM-12MM TROCAR
|
Facility
|
IP
|
$1,776.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.92 |
| Max. Negotiated Rate |
$1,705.25 |
| Rate for Payer: Aetna Commercial |
$1,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,385.51
|
| Rate for Payer: Cash Price |
$888.15
|
| Rate for Payer: Cigna Commercial |
$1,474.33
|
| Rate for Payer: First Health Commercial |
$1,687.48
|
| Rate for Payer: Humana Commercial |
$1,509.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,456.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,310.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,563.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,332.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$550.65
|
| Rate for Payer: PHCS Commercial |
$1,705.25
|
| Rate for Payer: United Healthcare All Payer |
$1,563.14
|
|
|
VISIPORT PLUS 5MM-12MM TROCAR
|
Facility
|
OP
|
$1,776.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$230.92 |
| Max. Negotiated Rate |
$1,705.25 |
| Rate for Payer: Aetna Commercial |
$1,367.75
|
| Rate for Payer: Anthem Medicaid |
$610.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,385.51
|
| Rate for Payer: Cash Price |
$888.15
|
| Rate for Payer: Cigna Commercial |
$1,474.33
|
| Rate for Payer: First Health Commercial |
$1,687.48
|
| Rate for Payer: Humana Commercial |
$1,509.86
|
| Rate for Payer: Humana KY Medicaid |
$610.87
|
| Rate for Payer: Kentucky WC Medicaid |
$617.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,456.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,310.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$623.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,563.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,332.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$230.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$550.65
|
| Rate for Payer: PHCS Commercial |
$1,705.25
|
| Rate for Payer: United Healthcare All Payer |
$1,563.14
|
|
|
VISI-PRO STENT 10*27*80
|
Facility
|
IP
|
$8,037.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.91 |
| Max. Negotiated Rate |
$7,716.24 |
| Rate for Payer: Aetna Commercial |
$6,189.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,269.44
|
| Rate for Payer: Cash Price |
$4,018.88
|
| Rate for Payer: Cigna Commercial |
$6,671.33
|
| Rate for Payer: First Health Commercial |
$7,635.86
|
| Rate for Payer: Humana Commercial |
$6,832.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,590.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,931.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,411.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,073.22
|
| Rate for Payer: Ohio Health Group HMO |
$6,028.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,607.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,491.70
|
| Rate for Payer: PHCS Commercial |
$7,716.24
|
| Rate for Payer: United Healthcare All Payer |
$7,073.22
|
|
|
VISI-PRO STENT 10*27*80
|
Facility
|
OP
|
$8,037.75
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,044.91 |
| Max. Negotiated Rate |
$7,716.24 |
| Rate for Payer: Aetna Commercial |
$6,189.07
|
| Rate for Payer: Anthem Medicaid |
$2,764.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,269.44
|
| Rate for Payer: Cash Price |
$4,018.88
|
| Rate for Payer: Cigna Commercial |
$6,671.33
|
| Rate for Payer: First Health Commercial |
$7,635.86
|
| Rate for Payer: Humana Commercial |
$6,832.09
|
| Rate for Payer: Humana KY Medicaid |
$2,764.18
|
| Rate for Payer: Kentucky WC Medicaid |
$2,792.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,590.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,931.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,411.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,819.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,073.22
|
| Rate for Payer: Ohio Health Group HMO |
$6,028.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,607.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,491.70
|
| Rate for Payer: PHCS Commercial |
$7,716.24
|
| Rate for Payer: United Healthcare All Payer |
$7,073.22
|
|
|
VISI-PRO STENT 10*37*80
|
Facility
|
OP
|
$5,227.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$679.58 |
| Max. Negotiated Rate |
$5,018.40 |
| Rate for Payer: Aetna Commercial |
$4,025.18
|
| Rate for Payer: Anthem Medicaid |
$1,797.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Cash Price |
$2,613.75
|
| Rate for Payer: Cigna Commercial |
$4,338.82
|
| Rate for Payer: First Health Commercial |
$4,966.12
|
| Rate for Payer: Humana Commercial |
$4,443.38
|
| Rate for Payer: Humana KY Medicaid |
$1,797.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,816.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,286.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,857.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,568.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,833.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,600.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,920.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,620.52
|
| Rate for Payer: PHCS Commercial |
$5,018.40
|
| Rate for Payer: United Healthcare All Payer |
$4,600.20
|
|
|
VISI-PRO STENT 10*37*80
|
Facility
|
IP
|
$5,227.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$679.58 |
| Max. Negotiated Rate |
$5,018.40 |
| Rate for Payer: Aetna Commercial |
$4,025.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Cash Price |
$2,613.75
|
| Rate for Payer: Cigna Commercial |
$4,338.82
|
| Rate for Payer: First Health Commercial |
$4,966.12
|
| Rate for Payer: Humana Commercial |
$4,443.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,286.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,857.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,568.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,600.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,920.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,620.52
|
| Rate for Payer: PHCS Commercial |
$5,018.40
|
| Rate for Payer: United Healthcare All Payer |
$4,600.20
|
|
|
VISI-PRO STENT 5*17*80
|
Facility
|
OP
|
$4,471.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$581.30 |
| Max. Negotiated Rate |
$4,292.64 |
| Rate for Payer: Aetna Commercial |
$3,443.06
|
| Rate for Payer: Anthem Medicaid |
$1,537.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,487.77
|
| Rate for Payer: Cash Price |
$2,235.75
|
| Rate for Payer: Cigna Commercial |
$3,711.34
|
| Rate for Payer: First Health Commercial |
$4,247.92
|
| Rate for Payer: Humana Commercial |
$3,800.78
|
| Rate for Payer: Humana KY Medicaid |
$1,537.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,553.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,666.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,299.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,341.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,568.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,934.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,353.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$894.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,386.16
|
| Rate for Payer: PHCS Commercial |
$4,292.64
|
| Rate for Payer: United Healthcare All Payer |
$3,934.92
|
|
|
VISI-PRO STENT 5*17*80
|
Facility
|
IP
|
$4,471.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$581.30 |
| Max. Negotiated Rate |
$4,292.64 |
| Rate for Payer: Aetna Commercial |
$3,443.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,487.77
|
| Rate for Payer: Cash Price |
$2,235.75
|
| Rate for Payer: Cigna Commercial |
$3,711.34
|
| Rate for Payer: First Health Commercial |
$4,247.92
|
| Rate for Payer: Humana Commercial |
$3,800.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,666.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,299.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,341.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,934.92
|
| Rate for Payer: Ohio Health Group HMO |
$3,353.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$894.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,386.16
|
| Rate for Payer: PHCS Commercial |
$4,292.64
|
| Rate for Payer: United Healthcare All Payer |
$3,934.92
|
|
|
VISI-PRO STENT 5*27*135
|
Facility
|
OP
|
$5,227.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$679.58 |
| Max. Negotiated Rate |
$5,018.40 |
| Rate for Payer: Aetna Commercial |
$4,025.18
|
| Rate for Payer: Anthem Medicaid |
$1,797.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Cash Price |
$2,613.75
|
| Rate for Payer: Cigna Commercial |
$4,338.82
|
| Rate for Payer: First Health Commercial |
$4,966.12
|
| Rate for Payer: Humana Commercial |
$4,443.38
|
| Rate for Payer: Humana KY Medicaid |
$1,797.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,816.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,286.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,857.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,568.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,833.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,600.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,920.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,620.52
|
| Rate for Payer: PHCS Commercial |
$5,018.40
|
| Rate for Payer: United Healthcare All Payer |
$4,600.20
|
|
|
VISI-PRO STENT 5*27*135
|
Facility
|
IP
|
$5,227.50
|
|
|
Service Code
|
HCPCS C1876
|
| Hospital Charge Code |
27000127
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$679.58 |
| Max. Negotiated Rate |
$5,018.40 |
| Rate for Payer: Aetna Commercial |
$4,025.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Cash Price |
$2,613.75
|
| Rate for Payer: Cigna Commercial |
$4,338.82
|
| Rate for Payer: First Health Commercial |
$4,966.12
|
| Rate for Payer: Humana Commercial |
$4,443.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,286.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,857.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,568.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,600.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,920.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,045.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$679.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,620.52
|
| Rate for Payer: PHCS Commercial |
$5,018.40
|
| Rate for Payer: United Healthcare All Payer |
$4,600.20
|
|
