|
WIRE SS TROC 048*18
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.42 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.54
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
WIRE SS TROC 048*18
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.42 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem Medicaid |
$183.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Humana KY Medicaid |
$183.64
|
| Rate for Payer: Kentucky WC Medicaid |
$185.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.54
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
WIRE SS TROC 048*24
|
Facility
|
OP
|
$551.88
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.74 |
| Max. Negotiated Rate |
$529.80 |
| Rate for Payer: Aetna Commercial |
$424.95
|
| Rate for Payer: Anthem Medicaid |
$189.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$430.47
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Cigna Commercial |
$458.06
|
| Rate for Payer: First Health Commercial |
$524.29
|
| Rate for Payer: Humana Commercial |
$469.10
|
| Rate for Payer: Humana KY Medicaid |
$189.79
|
| Rate for Payer: Kentucky WC Medicaid |
$191.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$452.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$407.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$193.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$485.65
|
| Rate for Payer: Ohio Health Group HMO |
$413.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$171.08
|
| Rate for Payer: PHCS Commercial |
$529.80
|
| Rate for Payer: United Healthcare All Payer |
$485.65
|
|
|
WIRE SS TROC 048*24
|
Facility
|
IP
|
$551.88
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.74 |
| Max. Negotiated Rate |
$529.80 |
| Rate for Payer: Aetna Commercial |
$424.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$430.47
|
| Rate for Payer: Cash Price |
$275.94
|
| Rate for Payer: Cigna Commercial |
$458.06
|
| Rate for Payer: First Health Commercial |
$524.29
|
| Rate for Payer: Humana Commercial |
$469.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$452.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$407.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$165.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$485.65
|
| Rate for Payer: Ohio Health Group HMO |
$413.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$110.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$171.08
|
| Rate for Payer: PHCS Commercial |
$529.80
|
| Rate for Payer: United Healthcare All Payer |
$485.65
|
|
|
WIRE TI 1.25 150MM
|
Facility
|
OP
|
$1,582.12
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$205.68 |
| Max. Negotiated Rate |
$1,518.84 |
| Rate for Payer: Aetna Commercial |
$1,218.23
|
| Rate for Payer: Anthem Medicaid |
$544.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,234.05
|
| Rate for Payer: Cash Price |
$791.06
|
| Rate for Payer: Cigna Commercial |
$1,313.16
|
| Rate for Payer: First Health Commercial |
$1,503.01
|
| Rate for Payer: Humana Commercial |
$1,344.80
|
| Rate for Payer: Humana KY Medicaid |
$544.09
|
| Rate for Payer: Kentucky WC Medicaid |
$549.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,297.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,167.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$474.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$555.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,392.27
|
| Rate for Payer: Ohio Health Group HMO |
$1,186.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$316.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$205.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$490.46
|
| Rate for Payer: PHCS Commercial |
$1,518.84
|
| Rate for Payer: United Healthcare All Payer |
$1,392.27
|
|
|
WIRE TI 1.25 150MM
|
Facility
|
IP
|
$1,582.12
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$205.68 |
| Max. Negotiated Rate |
$1,518.84 |
| Rate for Payer: Aetna Commercial |
$1,218.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,234.05
|
| Rate for Payer: Cash Price |
$791.06
|
| Rate for Payer: Cigna Commercial |
$1,313.16
|
| Rate for Payer: First Health Commercial |
$1,503.01
|
| Rate for Payer: Humana Commercial |
$1,344.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,297.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,167.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$474.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,392.27
|
| Rate for Payer: Ohio Health Group HMO |
$1,186.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$316.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$205.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$490.46
|
| Rate for Payer: PHCS Commercial |
$1,518.84
|
| Rate for Payer: United Healthcare All Payer |
$1,392.27
|
|
|
WIRE TI 1.6 150MM
|
Facility
|
IP
|
$1,161.75
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.03 |
| Max. Negotiated Rate |
$1,115.28 |
| Rate for Payer: Aetna Commercial |
$894.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.16
|
| Rate for Payer: Cash Price |
$580.88
|
| Rate for Payer: Cigna Commercial |
$964.25
|
| Rate for Payer: First Health Commercial |
$1,103.66
|
| Rate for Payer: Humana Commercial |
$987.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$952.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.34
|
| Rate for Payer: Ohio Health Group HMO |
$871.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.14
|
| Rate for Payer: PHCS Commercial |
$1,115.28
|
| Rate for Payer: United Healthcare All Payer |
$1,022.34
|
|
|
WIRE TI 1.6 150MM
|
Facility
|
OP
|
$1,161.75
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.03 |
| Max. Negotiated Rate |
$1,115.28 |
| Rate for Payer: Aetna Commercial |
$894.55
|
| Rate for Payer: Anthem Medicaid |
$399.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.16
|
| Rate for Payer: Cash Price |
$580.88
|
| Rate for Payer: Cigna Commercial |
$964.25
|
| Rate for Payer: First Health Commercial |
$1,103.66
|
| Rate for Payer: Humana Commercial |
$987.49
|
| Rate for Payer: Humana KY Medicaid |
$399.53
|
| Rate for Payer: Kentucky WC Medicaid |
$403.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$952.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$407.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.34
|
| Rate for Payer: Ohio Health Group HMO |
$871.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.14
|
| Rate for Payer: PHCS Commercial |
$1,115.28
|
| Rate for Payer: United Healthcare All Payer |
$1,022.34
|
|
|
WIRE TI 2.0 150MM
|
Facility
|
IP
|
$1,564.09
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.33 |
| Max. Negotiated Rate |
$1,501.53 |
| Rate for Payer: Aetna Commercial |
$1,204.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,219.99
|
| Rate for Payer: Cash Price |
$782.04
|
| Rate for Payer: Cigna Commercial |
$1,298.19
|
| Rate for Payer: First Health Commercial |
$1,485.89
|
| Rate for Payer: Humana Commercial |
$1,329.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,282.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,376.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$484.87
|
| Rate for Payer: PHCS Commercial |
$1,501.53
|
| Rate for Payer: United Healthcare All Payer |
$1,376.40
|
|
|
WIRE TI 2.0 150MM
|
Facility
|
OP
|
$1,564.09
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$203.33 |
| Max. Negotiated Rate |
$1,501.53 |
| Rate for Payer: Aetna Commercial |
$1,204.35
|
| Rate for Payer: Anthem Medicaid |
$537.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,219.99
|
| Rate for Payer: Cash Price |
$782.04
|
| Rate for Payer: Cigna Commercial |
$1,298.19
|
| Rate for Payer: First Health Commercial |
$1,485.89
|
| Rate for Payer: Humana Commercial |
$1,329.48
|
| Rate for Payer: Humana KY Medicaid |
$537.89
|
| Rate for Payer: Kentucky WC Medicaid |
$543.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,282.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,154.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$469.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$548.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,376.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,173.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$203.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$484.87
|
| Rate for Payer: PHCS Commercial |
$1,501.53
|
| Rate for Payer: United Healthcare All Payer |
$1,376.40
|
|
|
WIRE TIP TRO SM 1.6MMX150MM L
|
Facility
|
OP
|
$791.38
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.88 |
| Max. Negotiated Rate |
$759.72 |
| Rate for Payer: Aetna Commercial |
$609.36
|
| Rate for Payer: Anthem Medicaid |
$272.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$617.28
|
| Rate for Payer: Cash Price |
$395.69
|
| Rate for Payer: Cigna Commercial |
$656.85
|
| Rate for Payer: First Health Commercial |
$751.81
|
| Rate for Payer: Humana Commercial |
$672.67
|
| Rate for Payer: Humana KY Medicaid |
$272.16
|
| Rate for Payer: Kentucky WC Medicaid |
$274.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$648.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$584.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$277.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$696.41
|
| Rate for Payer: Ohio Health Group HMO |
$593.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$158.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.33
|
| Rate for Payer: PHCS Commercial |
$759.72
|
| Rate for Payer: United Healthcare All Payer |
$696.41
|
|
|
WIRE TIP TRO SM 1.6MMX150MM L
|
Facility
|
IP
|
$791.38
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$102.88 |
| Max. Negotiated Rate |
$759.72 |
| Rate for Payer: Aetna Commercial |
$609.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$617.28
|
| Rate for Payer: Cash Price |
$395.69
|
| Rate for Payer: Cigna Commercial |
$656.85
|
| Rate for Payer: First Health Commercial |
$751.81
|
| Rate for Payer: Humana Commercial |
$672.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$648.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$584.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$696.41
|
| Rate for Payer: Ohio Health Group HMO |
$593.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$158.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$102.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$245.33
|
| Rate for Payer: PHCS Commercial |
$759.72
|
| Rate for Payer: United Healthcare All Payer |
$696.41
|
|
|
WIRE WHISPER EDS CSJ 4648
|
Facility
|
OP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem Medicaid |
$395.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Humana KY Medicaid |
$395.83
|
| Rate for Payer: Kentucky WC Medicaid |
$399.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$403.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
WIRE WHISPER EDS CSJ 4648
|
Facility
|
IP
|
$1,151.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.63 |
| Max. Negotiated Rate |
$1,104.96 |
| Rate for Payer: Aetna Commercial |
$886.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$897.78
|
| Rate for Payer: Cash Price |
$575.50
|
| Rate for Payer: Cigna Commercial |
$955.33
|
| Rate for Payer: First Health Commercial |
$1,093.45
|
| Rate for Payer: Humana Commercial |
$978.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$943.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$849.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,012.88
|
| Rate for Payer: Ohio Health Group HMO |
$863.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$230.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$149.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$356.81
|
| Rate for Payer: PHCS Commercial |
$1,104.96
|
| Rate for Payer: United Healthcare All Payer |
$1,012.88
|
|
|
WIRE WITH STOPPER 300MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
WIRE WITH STOPPER 300MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
WIRE WITH STOPPER 400MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
WIRE WITH STOPPER 400MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
WND PREP F/N/HF/G ADDL CM
|
Professional
|
Both
|
$2,545.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
76100174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$2,545.28 |
| Rate for Payer: Aetna Commercial |
$136.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.37
|
| Rate for Payer: Anthem Medicaid |
$65.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,545.28
|
| Rate for Payer: Cash Price |
$1,272.64
|
| Rate for Payer: Cash Price |
$1,272.64
|
| Rate for Payer: Cigna Commercial |
$128.36
|
| Rate for Payer: Healthspan PPO |
$139.02
|
| Rate for Payer: Humana Medicaid |
$65.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.18
|
| Rate for Payer: Molina Healthcare Passport |
$65.86
|
| Rate for Payer: Multiplan PHCS |
$1,527.17
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,781.70
|
| Rate for Payer: UHCCP Medicaid |
$48.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.52
|
|
|
WND PREP F/N/HF/G ADDL CM
|
Facility
|
OP
|
$2,545.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
76100174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.89 |
| Max. Negotiated Rate |
$2,443.47 |
| Rate for Payer: Aetna Commercial |
$1,959.87
|
| Rate for Payer: Anthem Medicaid |
$875.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,985.32
|
| Rate for Payer: Cash Price |
$1,272.64
|
| Rate for Payer: Cigna Commercial |
$2,112.58
|
| Rate for Payer: First Health Commercial |
$2,418.02
|
| Rate for Payer: Humana Commercial |
$2,163.49
|
| Rate for Payer: Humana KY Medicaid |
$875.32
|
| Rate for Payer: Kentucky WC Medicaid |
$884.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,087.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,878.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$763.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$892.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,239.85
|
| Rate for Payer: Ohio Health Group HMO |
$1,908.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$509.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$330.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$789.04
|
| Rate for Payer: PHCS Commercial |
$2,443.47
|
| Rate for Payer: United Healthcare All Payer |
$2,239.85
|
|
|
WND PREP F/N/HF/G ADDL CM
|
Facility
|
IP
|
$2,545.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
76100174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$330.89 |
| Max. Negotiated Rate |
$2,443.47 |
| Rate for Payer: Aetna Commercial |
$1,959.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,985.32
|
| Rate for Payer: Cash Price |
$1,272.64
|
| Rate for Payer: Cigna Commercial |
$2,112.58
|
| Rate for Payer: First Health Commercial |
$2,418.02
|
| Rate for Payer: Humana Commercial |
$2,163.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,087.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,878.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$763.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,239.85
|
| Rate for Payer: Ohio Health Group HMO |
$1,908.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$509.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$330.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$789.04
|
| Rate for Payer: PHCS Commercial |
$2,443.47
|
| Rate for Payer: United Healthcare All Payer |
$2,239.85
|
|
|
WND PREP F/N/HF/G ADDL CM(P
|
Professional
|
Both
|
$345.00
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
761P0174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$46.37 |
| Max. Negotiated Rate |
$345.00 |
| Rate for Payer: Aetna Commercial |
$136.93
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.37
|
| Rate for Payer: Anthem Medicaid |
$65.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.00
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cash Price |
$172.50
|
| Rate for Payer: Cigna Commercial |
$128.36
|
| Rate for Payer: Healthspan PPO |
$139.02
|
| Rate for Payer: Humana Medicaid |
$65.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.18
|
| Rate for Payer: Molina Healthcare Passport |
$65.86
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$241.50
|
| Rate for Payer: UHCCP Medicaid |
$48.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.52
|
|
|
WND PREP F/N/HF/G ADDL CM(T
|
Facility
|
OP
|
$2,200.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
761T0174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$286.04 |
| Max. Negotiated Rate |
$2,112.27 |
| Rate for Payer: Aetna Commercial |
$1,694.22
|
| Rate for Payer: Anthem Medicaid |
$756.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,716.22
|
| Rate for Payer: Cash Price |
$1,100.14
|
| Rate for Payer: Cigna Commercial |
$1,826.23
|
| Rate for Payer: First Health Commercial |
$2,090.27
|
| Rate for Payer: Humana Commercial |
$1,870.24
|
| Rate for Payer: Humana KY Medicaid |
$756.68
|
| Rate for Payer: Kentucky WC Medicaid |
$764.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,804.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,623.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$660.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$771.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,936.25
|
| Rate for Payer: Ohio Health Group HMO |
$1,650.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$682.09
|
| Rate for Payer: PHCS Commercial |
$2,112.27
|
| Rate for Payer: United Healthcare All Payer |
$1,936.25
|
|
|
WND PREP F/N/HF/G ADDL CM(T
|
Facility
|
IP
|
$2,200.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
761T0174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$286.04 |
| Max. Negotiated Rate |
$2,112.27 |
| Rate for Payer: Aetna Commercial |
$1,694.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,716.22
|
| Rate for Payer: Cash Price |
$1,100.14
|
| Rate for Payer: Cigna Commercial |
$1,826.23
|
| Rate for Payer: First Health Commercial |
$2,090.27
|
| Rate for Payer: Humana Commercial |
$1,870.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,804.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,623.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$660.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,936.25
|
| Rate for Payer: Ohio Health Group HMO |
$1,650.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$440.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$286.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$682.09
|
| Rate for Payer: PHCS Commercial |
$2,112.27
|
| Rate for Payer: United Healthcare All Payer |
$1,936.25
|
|
|
WOLVERINE CUT. BALLOON 2*10
|
Facility
|
IP
|
$4,456.94
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$579.40 |
| Max. Negotiated Rate |
$4,278.66 |
| Rate for Payer: Aetna Commercial |
$3,431.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,476.41
|
| Rate for Payer: Cash Price |
$2,228.47
|
| Rate for Payer: Cigna Commercial |
$3,699.26
|
| Rate for Payer: First Health Commercial |
$4,234.09
|
| Rate for Payer: Humana Commercial |
$3,788.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,654.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,289.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,337.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,922.11
|
| Rate for Payer: Ohio Health Group HMO |
$3,342.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$891.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$579.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,381.65
|
| Rate for Payer: PHCS Commercial |
$4,278.66
|
| Rate for Payer: United Healthcare All Payer |
$3,922.11
|
|
