|
WIRE SS TROC 048*18
|
Facility
|
OP
|
$540.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$162.15 |
| Max. Negotiated Rate |
$518.88 |
| Rate for Payer: Aetna Commercial |
$416.19
|
| Rate for Payer: Anthem Medicaid |
$185.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.59
|
| Rate for Payer: Cash Price |
$270.25
|
| Rate for Payer: Cigna Commercial |
$448.62
|
| Rate for Payer: First Health Commercial |
$513.48
|
| Rate for Payer: Humana Commercial |
$459.43
|
| Rate for Payer: Humana KY Medicaid |
$185.88
|
| Rate for Payer: Kentucky WC Medicaid |
$187.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$443.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$189.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.64
|
| Rate for Payer: Ohio Health Group HMO |
$405.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$432.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.94
|
| Rate for Payer: PHCS Commercial |
$518.88
|
| Rate for Payer: United Healthcare All Payer |
$475.64
|
|
|
WIRE SS TROC 048*18
|
Facility
|
IP
|
$540.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$162.15 |
| Max. Negotiated Rate |
$518.88 |
| Rate for Payer: Aetna Commercial |
$416.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$421.59
|
| Rate for Payer: Cash Price |
$270.25
|
| Rate for Payer: Cigna Commercial |
$448.62
|
| Rate for Payer: First Health Commercial |
$513.48
|
| Rate for Payer: Humana Commercial |
$459.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$443.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$398.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$475.64
|
| Rate for Payer: Ohio Health Group HMO |
$405.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$432.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$470.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$372.94
|
| Rate for Payer: PHCS Commercial |
$518.88
|
| Rate for Payer: United Healthcare All Payer |
$475.64
|
|
|
WIRE SS TROC 048*24
|
Facility
|
OP
|
$559.06
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.72 |
| Max. Negotiated Rate |
$536.70 |
| Rate for Payer: Aetna Commercial |
$430.48
|
| Rate for Payer: Anthem Medicaid |
$192.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.07
|
| Rate for Payer: Cash Price |
$279.53
|
| Rate for Payer: Cigna Commercial |
$464.02
|
| Rate for Payer: First Health Commercial |
$531.11
|
| Rate for Payer: Humana Commercial |
$475.20
|
| Rate for Payer: Humana KY Medicaid |
$192.26
|
| Rate for Payer: Kentucky WC Medicaid |
$194.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.97
|
| Rate for Payer: Ohio Health Group HMO |
$419.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.75
|
| Rate for Payer: PHCS Commercial |
$536.70
|
| Rate for Payer: United Healthcare All Payer |
$491.97
|
|
|
WIRE SS TROC 048*24
|
Facility
|
IP
|
$559.06
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.72 |
| Max. Negotiated Rate |
$536.70 |
| Rate for Payer: Aetna Commercial |
$430.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.07
|
| Rate for Payer: Cash Price |
$279.53
|
| Rate for Payer: Cigna Commercial |
$464.02
|
| Rate for Payer: First Health Commercial |
$531.11
|
| Rate for Payer: Humana Commercial |
$475.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.97
|
| Rate for Payer: Ohio Health Group HMO |
$419.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.75
|
| Rate for Payer: PHCS Commercial |
$536.70
|
| Rate for Payer: United Healthcare All Payer |
$491.97
|
|
|
WIRE TI 1.25 150MM
|
Facility
|
IP
|
$1,560.58
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$468.17 |
| Max. Negotiated Rate |
$1,498.16 |
| Rate for Payer: Aetna Commercial |
$1,201.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,217.25
|
| Rate for Payer: Cash Price |
$780.29
|
| Rate for Payer: Cigna Commercial |
$1,295.28
|
| Rate for Payer: First Health Commercial |
$1,482.55
|
| Rate for Payer: Humana Commercial |
$1,326.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,279.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,151.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,373.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,170.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,248.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,357.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,076.80
|
| Rate for Payer: PHCS Commercial |
$1,498.16
|
| Rate for Payer: United Healthcare All Payer |
$1,373.31
|
|
|
WIRE TI 1.25 150MM
|
Facility
|
OP
|
$1,560.58
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$468.17 |
| Max. Negotiated Rate |
$1,498.16 |
| Rate for Payer: Aetna Commercial |
$1,201.65
|
| Rate for Payer: Anthem Medicaid |
$536.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,217.25
|
| Rate for Payer: Cash Price |
$780.29
|
| Rate for Payer: Cigna Commercial |
$1,295.28
|
| Rate for Payer: First Health Commercial |
$1,482.55
|
| Rate for Payer: Humana Commercial |
$1,326.49
|
| Rate for Payer: Humana KY Medicaid |
$536.68
|
| Rate for Payer: Kentucky WC Medicaid |
$542.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,279.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,151.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$547.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,373.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,170.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,248.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,357.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,076.80
|
| Rate for Payer: PHCS Commercial |
$1,498.16
|
| Rate for Payer: United Healthcare All Payer |
$1,373.31
|
|
|
WIRE TI 1.6 150MM
|
Facility
|
OP
|
$1,212.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$363.75 |
| Max. Negotiated Rate |
$1,164.00 |
| Rate for Payer: Aetna Commercial |
$933.62
|
| Rate for Payer: Anthem Medicaid |
$416.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$945.75
|
| Rate for Payer: Cash Price |
$606.25
|
| Rate for Payer: Cigna Commercial |
$1,006.38
|
| Rate for Payer: First Health Commercial |
$1,151.88
|
| Rate for Payer: Humana Commercial |
$1,030.62
|
| Rate for Payer: Humana KY Medicaid |
$416.98
|
| Rate for Payer: Kentucky WC Medicaid |
$421.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$994.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$894.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$363.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$425.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,067.00
|
| Rate for Payer: Ohio Health Group HMO |
$909.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$970.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,054.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$836.62
|
| Rate for Payer: PHCS Commercial |
$1,164.00
|
| Rate for Payer: United Healthcare All Payer |
$1,067.00
|
|
|
WIRE TI 1.6 150MM
|
Facility
|
IP
|
$1,212.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$363.75 |
| Max. Negotiated Rate |
$1,164.00 |
| Rate for Payer: Aetna Commercial |
$933.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$945.75
|
| Rate for Payer: Cash Price |
$606.25
|
| Rate for Payer: Cigna Commercial |
$1,006.38
|
| Rate for Payer: First Health Commercial |
$1,151.88
|
| Rate for Payer: Humana Commercial |
$1,030.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$994.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$894.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$363.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,067.00
|
| Rate for Payer: Ohio Health Group HMO |
$909.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$970.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,054.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$836.62
|
| Rate for Payer: PHCS Commercial |
$1,164.00
|
| Rate for Payer: United Healthcare All Payer |
$1,067.00
|
|
|
WIRE TI 2.0 150MM
|
Facility
|
OP
|
$1,541.01
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.30 |
| Max. Negotiated Rate |
$1,479.37 |
| Rate for Payer: Aetna Commercial |
$1,186.58
|
| Rate for Payer: Anthem Medicaid |
$529.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,201.99
|
| Rate for Payer: Cash Price |
$770.51
|
| Rate for Payer: Cigna Commercial |
$1,279.04
|
| Rate for Payer: First Health Commercial |
$1,463.96
|
| Rate for Payer: Humana Commercial |
$1,309.86
|
| Rate for Payer: Humana KY Medicaid |
$529.95
|
| Rate for Payer: Kentucky WC Medicaid |
$535.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,263.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.09
|
| Rate for Payer: Ohio Health Group HMO |
$1,155.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,232.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,340.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.30
|
| Rate for Payer: PHCS Commercial |
$1,479.37
|
| Rate for Payer: United Healthcare All Payer |
$1,356.09
|
|
|
WIRE TI 2.0 150MM
|
Facility
|
IP
|
$1,541.01
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.30 |
| Max. Negotiated Rate |
$1,479.37 |
| Rate for Payer: Aetna Commercial |
$1,186.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,201.99
|
| Rate for Payer: Cash Price |
$770.51
|
| Rate for Payer: Cigna Commercial |
$1,279.04
|
| Rate for Payer: First Health Commercial |
$1,463.96
|
| Rate for Payer: Humana Commercial |
$1,309.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,263.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,137.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.09
|
| Rate for Payer: Ohio Health Group HMO |
$1,155.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,232.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,340.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.30
|
| Rate for Payer: PHCS Commercial |
$1,479.37
|
| Rate for Payer: United Healthcare All Payer |
$1,356.09
|
|
|
WIRE TIP TRO SM 1.6MMX150MM L
|
Facility
|
IP
|
$812.65
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.79 |
| Max. Negotiated Rate |
$780.14 |
| Rate for Payer: Aetna Commercial |
$625.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$633.87
|
| Rate for Payer: Cash Price |
$406.32
|
| Rate for Payer: Cigna Commercial |
$674.50
|
| Rate for Payer: First Health Commercial |
$772.02
|
| Rate for Payer: Humana Commercial |
$690.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$666.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$599.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$715.13
|
| Rate for Payer: Ohio Health Group HMO |
$609.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.73
|
| Rate for Payer: PHCS Commercial |
$780.14
|
| Rate for Payer: United Healthcare All Payer |
$715.13
|
|
|
WIRE TIP TRO SM 1.6MMX150MM L
|
Facility
|
OP
|
$812.65
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$243.79 |
| Max. Negotiated Rate |
$780.14 |
| Rate for Payer: Aetna Commercial |
$625.74
|
| Rate for Payer: Anthem Medicaid |
$279.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$633.87
|
| Rate for Payer: Cash Price |
$406.32
|
| Rate for Payer: Cigna Commercial |
$674.50
|
| Rate for Payer: First Health Commercial |
$772.02
|
| Rate for Payer: Humana Commercial |
$690.75
|
| Rate for Payer: Humana KY Medicaid |
$279.47
|
| Rate for Payer: Kentucky WC Medicaid |
$282.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$666.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$599.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$243.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$285.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$715.13
|
| Rate for Payer: Ohio Health Group HMO |
$609.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$560.73
|
| Rate for Payer: PHCS Commercial |
$780.14
|
| Rate for Payer: United Healthcare All Payer |
$715.13
|
|
|
WIRE WHISPER EDS CSJ 4648
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
WIRE WHISPER EDS CSJ 4648
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
WIRE WITH STOPPER 300MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| 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 |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| 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 |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| 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 |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
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 |
$763.58 |
| 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 |
$2,036.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,214.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,756.24
|
| 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
|
OP
|
$2,545.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
76100174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$763.58 |
| 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 |
$2,036.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,214.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,756.24
|
| 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
|
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 |
$1,527.17 |
| Rate for Payer: Aetna Commercial |
$136.93
|
| Rate for Payer: Ambetter Exchange |
$84.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.37
|
| Rate for Payer: Anthem Medicaid |
$84.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$84.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$84.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$101.90
|
| 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 |
$84.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$84.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.81
|
| Rate for Payer: Molina Healthcare Passport |
$84.13
|
| Rate for Payer: Multiplan PHCS |
$1,527.17
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$110.40
|
| Rate for Payer: UHCCP Medicaid |
$48.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$84.92
|
|
|
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 |
$207.00 |
| Rate for Payer: Aetna Commercial |
$136.93
|
| Rate for Payer: Ambetter Exchange |
$84.92
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$46.37
|
| Rate for Payer: Anthem Medicaid |
$84.13
|
| Rate for Payer: Buckeye Individual/Medicaid |
$84.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$84.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$101.90
|
| 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 |
$84.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$114.96
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$84.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$84.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$85.81
|
| Rate for Payer: Molina Healthcare Passport |
$84.13
|
| Rate for Payer: Multiplan PHCS |
$207.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$110.40
|
| Rate for Payer: UHCCP Medicaid |
$48.69
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$84.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$84.92
|
|
|
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 |
$660.08 |
| 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 |
$1,760.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,914.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,518.19
|
| 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
|
OP
|
$2,200.28
|
|
|
Service Code
|
HCPCS 15005
|
| Hospital Charge Code |
761T0174
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$660.08 |
| 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 |
$1,760.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,914.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,518.19
|
| 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
|
$4,418.15
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,325.44 |
| Max. Negotiated Rate |
$4,241.42 |
| Rate for Payer: Aetna Commercial |
$3,401.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,446.16
|
| Rate for Payer: Cash Price |
$2,209.07
|
| Rate for Payer: Cigna Commercial |
$3,667.06
|
| Rate for Payer: First Health Commercial |
$4,197.24
|
| Rate for Payer: Humana Commercial |
$3,755.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,622.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,260.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,325.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,887.97
|
| Rate for Payer: Ohio Health Group HMO |
$3,313.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,534.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,843.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,048.52
|
| Rate for Payer: PHCS Commercial |
$4,241.42
|
| Rate for Payer: United Healthcare All Payer |
$3,887.97
|
|
