|
VEGA PS GLIDING SURF T3/T3+ 12
|
Facility
|
IP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
VEGA PS GLIDING SURF TT2/2+10M
|
Facility
|
IP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
VEGA PS GLIDING SURF TT2/2+10M
|
Facility
|
OP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem Medicaid |
$3,308.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Humana KY Medicaid |
$3,308.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3,342.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,374.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
VEGA PS GLIDNG SRF T3/T3+ 20MM
|
Facility
|
IP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
VEGA PS GLIDNG SRF T3/T3+ 20MM
|
Facility
|
OP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem Medicaid |
$3,308.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Humana KY Medicaid |
$3,308.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3,342.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,374.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
VEGA TIBIA PLATEAU CEM T2 70*4
|
Facility
|
OP
|
$13,042.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem Medicaid |
$4,485.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Humana KY Medicaid |
$4,485.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,530.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,575.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
VEGA TIBIA PLATEAU CEM T2 70*4
|
Facility
|
IP
|
$13,042.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
VEIN BYPASS GRAFT
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 35372
|
| Hospital Charge Code |
76101389
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$716.15 |
| Max. Negotiated Rate |
$1,751.15 |
| Rate for Payer: Aetna Commercial |
$1,751.15
|
| Rate for Payer: Ambetter Exchange |
$913.85
|
| Rate for Payer: Anthem Medicaid |
$716.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$913.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$913.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,096.62
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,685.99
|
| Rate for Payer: Healthspan PPO |
$1,721.73
|
| Rate for Payer: Humana Medicaid |
$716.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,348.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$913.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$913.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$730.47
|
| Rate for Payer: Molina Healthcare Passport |
$716.15
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,188.01
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$723.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$913.85
|
|
|
VEIN BYPASS GRAFT
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35585
|
| Hospital Charge Code |
76101404
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VEIN BYPASS GRAFT
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35585
|
| Hospital Charge Code |
76101404
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VEIN BYPASS GRAFT
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 35372
|
| Hospital Charge Code |
76101389
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Humana KY Medicaid |
$859.75
|
| Rate for Payer: Kentucky WC Medicaid |
$868.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
VEIN BYPASS GRAFT
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 35372
|
| Hospital Charge Code |
76101389
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
VEIN BYPASS GRAFT
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35583
|
| Hospital Charge Code |
76101403
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VEIN BYPASS GRAFT
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35585
|
| Hospital Charge Code |
76101404
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$2,951.13 |
| Rate for Payer: Aetna Commercial |
$2,951.13
|
| Rate for Payer: Ambetter Exchange |
$1,565.30
|
| Rate for Payer: Anthem Medicaid |
$1,287.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,565.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,565.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,878.36
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,811.07
|
| Rate for Payer: Healthspan PPO |
$2,901.54
|
| Rate for Payer: Humana Medicaid |
$1,287.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,311.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,565.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,565.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,312.80
|
| Rate for Payer: Molina Healthcare Passport |
$1,287.06
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,034.89
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,299.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,565.30
|
|
|
VEIN BYPASS GRAFT
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35583
|
| Hospital Charge Code |
76101403
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$900.00 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna Commercial |
$2,310.00
|
| Rate for Payer: Anthem Medicaid |
$1,031.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,340.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,490.00
|
| Rate for Payer: First Health Commercial |
$2,850.00
|
| Rate for Payer: Humana Commercial |
$2,550.00
|
| Rate for Payer: Humana KY Medicaid |
$1,031.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1,042.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,460.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,214.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$900.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,052.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,610.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,070.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
VEIN BYPASS GRAFT
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35583
|
| Hospital Charge Code |
76101403
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$2,510.52 |
| Rate for Payer: Aetna Commercial |
$2,510.52
|
| Rate for Payer: Ambetter Exchange |
$1,351.22
|
| Rate for Payer: Anthem Medicaid |
$1,117.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,351.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,351.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,621.46
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,379.76
|
| Rate for Payer: Healthspan PPO |
$2,468.33
|
| Rate for Payer: Humana Medicaid |
$1,117.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,987.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,351.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,351.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,139.55
|
| Rate for Payer: Molina Healthcare Passport |
$1,117.21
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,756.59
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,128.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,351.22
|
|
|
VEIN BYPASS GRAFT(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35585
|
| Hospital Charge Code |
761P1404
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$2,951.13 |
| Rate for Payer: Aetna Commercial |
$2,951.13
|
| Rate for Payer: Ambetter Exchange |
$1,565.30
|
| Rate for Payer: Anthem Medicaid |
$1,287.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,565.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,565.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,878.36
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,811.07
|
| Rate for Payer: Healthspan PPO |
$2,901.54
|
| Rate for Payer: Humana Medicaid |
$1,287.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,311.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,565.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,565.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,312.80
|
| Rate for Payer: Molina Healthcare Passport |
$1,287.06
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,034.89
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,299.93
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,565.30
|
|
|
VEIN BYPASS GRAFT(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35583
|
| Hospital Charge Code |
761P1403
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,050.00 |
| Max. Negotiated Rate |
$2,510.52 |
| Rate for Payer: Aetna Commercial |
$2,510.52
|
| Rate for Payer: Ambetter Exchange |
$1,351.22
|
| Rate for Payer: Anthem Medicaid |
$1,117.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,351.22
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,351.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,621.46
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$2,379.76
|
| Rate for Payer: Healthspan PPO |
$2,468.33
|
| Rate for Payer: Humana Medicaid |
$1,117.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,987.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,351.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,351.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,139.55
|
| Rate for Payer: Molina Healthcare Passport |
$1,117.21
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,756.59
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,128.38
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,351.22
|
|
|
VEIN BYPASS GRAFT(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 35372
|
| Hospital Charge Code |
761P1389
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$716.15 |
| Max. Negotiated Rate |
$1,751.15 |
| Rate for Payer: Aetna Commercial |
$1,751.15
|
| Rate for Payer: Ambetter Exchange |
$913.85
|
| Rate for Payer: Anthem Medicaid |
$716.15
|
| Rate for Payer: Buckeye Individual/Medicaid |
$913.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$913.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,096.62
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,685.99
|
| Rate for Payer: Healthspan PPO |
$1,721.73
|
| Rate for Payer: Humana Medicaid |
$716.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,348.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$913.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$913.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$730.47
|
| Rate for Payer: Molina Healthcare Passport |
$716.15
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,188.01
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$723.31
|
| Rate for Payer: Wellcare Medicare Advantage |
$913.85
|
|
|
VEIN HARVEST
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS 33508
|
| Hospital Charge Code |
76101296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
VEIN HARVEST
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 33508
|
| Hospital Charge Code |
76101296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$28.18
|
| Rate for Payer: Ambetter Exchange |
$15.02
|
| Rate for Payer: Anthem Medicaid |
$12.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$15.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$15.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.02
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$26.43
|
| Rate for Payer: Healthspan PPO |
$27.71
|
| Rate for Payer: Humana Medicaid |
$12.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$15.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.78
|
| Rate for Payer: Molina Healthcare Passport |
$12.53
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$19.53
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$15.02
|
|
|
VEIN HARVEST
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS 33508
|
| Hospital Charge Code |
76101296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$80.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$69.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
VEIN HARVEST(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 33508
|
| Hospital Charge Code |
761P1296
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$12.53 |
| Max. Negotiated Rate |
$60.00 |
| Rate for Payer: Aetna Commercial |
$28.18
|
| Rate for Payer: Ambetter Exchange |
$15.02
|
| Rate for Payer: Anthem Medicaid |
$12.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$15.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$15.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.02
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$26.43
|
| Rate for Payer: Healthspan PPO |
$27.71
|
| Rate for Payer: Humana Medicaid |
$12.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$22.92
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$15.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$15.02
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.78
|
| Rate for Payer: Molina Healthcare Passport |
$12.53
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$19.53
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$15.02
|
|
|
VEIN MAPPING
|
Professional
|
Both
|
$812.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
32000295
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$568.40 |
| Rate for Payer: Cash Price |
$406.00
|
| Rate for Payer: Cash Price |
$406.00
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Multiplan PHCS |
$487.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$568.40
|
| Rate for Payer: UHCCP Medicaid |
$284.20
|
|
|
VEIN MAPPING
|
Facility
|
OP
|
$812.00
|
|
|
Service Code
|
HCPCS 93799
|
| Hospital Charge Code |
32000295
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$144.57 |
| Max. Negotiated Rate |
$779.52 |
| Rate for Payer: Aetna Commercial |
$625.24
|
| Rate for Payer: Anthem Medicaid |
$279.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$144.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$633.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$202.40
|
| Rate for Payer: CareSource Just4Me Medicare |
$195.17
|
| Rate for Payer: Cash Price |
$406.00
|
| Rate for Payer: Cash Price |
$406.00
|
| Rate for Payer: Cigna Commercial |
$673.96
|
| Rate for Payer: First Health Commercial |
$771.40
|
| Rate for Payer: Humana Commercial |
$690.20
|
| Rate for Payer: Humana KY Medicaid |
$279.25
|
| Rate for Payer: Humana Medicare Advantage |
$144.57
|
| Rate for Payer: Kentucky WC Medicaid |
$282.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$665.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$599.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$284.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$714.56
|
| Rate for Payer: Ohio Health Group HMO |
$609.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$649.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.28
|
| Rate for Payer: PHCS Commercial |
$779.52
|
| Rate for Payer: United Healthcare All Payer |
$714.56
|
|
