|
BX SOFT TISS UPPER ARM SUPRF
|
Facility
|
IP
|
$4,114.50
|
|
|
Service Code
|
HCPCS 24065
|
| Hospital Charge Code |
76100498
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$534.88 |
| Max. Negotiated Rate |
$3,949.92 |
| Rate for Payer: Aetna Commercial |
$3,168.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,209.31
|
| Rate for Payer: Cash Price |
$2,057.25
|
| Rate for Payer: Cigna Commercial |
$3,415.04
|
| Rate for Payer: First Health Commercial |
$3,908.78
|
| Rate for Payer: Humana Commercial |
$3,497.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,373.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,036.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,234.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,620.76
|
| Rate for Payer: Ohio Health Group HMO |
$3,085.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$822.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$534.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,275.50
|
| Rate for Payer: PHCS Commercial |
$3,949.92
|
| Rate for Payer: United Healthcare All Payer |
$3,620.76
|
|
|
BX SOFT TISS UPPER ARM SUPRF
|
Professional
|
Both
|
$4,114.50
|
|
|
Service Code
|
HCPCS 24065
|
| Hospital Charge Code |
76100498
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.59 |
| Max. Negotiated Rate |
$4,114.50 |
| Rate for Payer: Aetna Commercial |
$235.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$89.89
|
| Rate for Payer: Anthem Medicaid |
$72.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,114.50
|
| Rate for Payer: Cash Price |
$2,057.25
|
| Rate for Payer: Cash Price |
$2,057.25
|
| Rate for Payer: Cigna Commercial |
$352.08
|
| Rate for Payer: Healthspan PPO |
$310.33
|
| Rate for Payer: Humana Medicaid |
$72.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$207.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.04
|
| Rate for Payer: Molina Healthcare Passport |
$72.59
|
| Rate for Payer: Multiplan PHCS |
$2,468.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,880.15
|
| Rate for Payer: UHCCP Medicaid |
$94.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.32
|
|
|
BX SOFT TISS UPPER ARM SUPRF(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 24065
|
| Hospital Charge Code |
761P0498
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$72.59 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$235.03
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$89.89
|
| Rate for Payer: Anthem Medicaid |
$72.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$352.08
|
| Rate for Payer: Healthspan PPO |
$310.33
|
| Rate for Payer: Humana Medicaid |
$72.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$207.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$74.04
|
| Rate for Payer: Molina Healthcare Passport |
$72.59
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$94.38
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$73.32
|
|
|
BX SOFT TISS UPPER ARM SUPRF(T
|
Facility
|
OP
|
$3,664.50
|
|
|
Service Code
|
HCPCS 24065
|
| Hospital Charge Code |
761T0498
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$476.38 |
| Max. Negotiated Rate |
$3,517.92 |
| Rate for Payer: Aetna Commercial |
$2,821.66
|
| Rate for Payer: Anthem Medicaid |
$1,260.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,402.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,858.31
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,962.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,892.73
|
| Rate for Payer: Cash Price |
$1,832.25
|
| Rate for Payer: Cash Price |
$1,832.25
|
| Rate for Payer: Cigna Commercial |
$3,041.54
|
| Rate for Payer: First Health Commercial |
$3,481.28
|
| Rate for Payer: Humana Commercial |
$3,114.82
|
| Rate for Payer: Humana KY Medicaid |
$1,260.22
|
| Rate for Payer: Humana Medicare Advantage |
$1,402.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,273.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,004.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,704.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,682.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,285.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,224.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,748.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$732.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,136.00
|
| Rate for Payer: PHCS Commercial |
$3,517.92
|
| Rate for Payer: United Healthcare All Payer |
$3,224.76
|
|
|
BX SOFT TISS UPPER ARM SUPRF(T
|
Facility
|
IP
|
$3,664.50
|
|
|
Service Code
|
HCPCS 24065
|
| Hospital Charge Code |
761T0498
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$476.38 |
| Max. Negotiated Rate |
$3,517.92 |
| Rate for Payer: Aetna Commercial |
$2,821.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,858.31
|
| Rate for Payer: Cash Price |
$1,832.25
|
| Rate for Payer: Cigna Commercial |
$3,041.54
|
| Rate for Payer: First Health Commercial |
$3,481.28
|
| Rate for Payer: Humana Commercial |
$3,114.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,004.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,704.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,099.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,224.76
|
| Rate for Payer: Ohio Health Group HMO |
$2,748.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$732.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,136.00
|
| Rate for Payer: PHCS Commercial |
$3,517.92
|
| Rate for Payer: United Healthcare All Payer |
$3,224.76
|
|
|
BX TONGUE
|
Professional
|
Both
|
$2,021.45
|
|
|
Service Code
|
HCPCS 41100
|
| Hospital Charge Code |
76101651
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.04 |
| Max. Negotiated Rate |
$2,021.45 |
| Rate for Payer: Aetna Commercial |
$157.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.21
|
| Rate for Payer: Anthem Medicaid |
$59.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,021.45
|
| Rate for Payer: Cash Price |
$1,010.72
|
| Rate for Payer: Cash Price |
$1,010.72
|
| Rate for Payer: Cigna Commercial |
$223.64
|
| Rate for Payer: Healthspan PPO |
$194.48
|
| Rate for Payer: Humana Medicaid |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$139.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.22
|
| Rate for Payer: Molina Healthcare Passport |
$59.04
|
| Rate for Payer: Multiplan PHCS |
$1,212.87
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,415.02
|
| Rate for Payer: UHCCP Medicaid |
$80.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.63
|
|
|
BX TONGUE
|
Facility
|
IP
|
$2,021.45
|
|
|
Service Code
|
HCPCS 41100
|
| Hospital Charge Code |
76101651
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.79 |
| Max. Negotiated Rate |
$1,940.59 |
| Rate for Payer: Aetna Commercial |
$1,556.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,576.73
|
| Rate for Payer: Cash Price |
$1,010.72
|
| Rate for Payer: Cigna Commercial |
$1,677.80
|
| Rate for Payer: First Health Commercial |
$1,920.38
|
| Rate for Payer: Humana Commercial |
$1,718.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,657.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,491.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$606.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,778.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,516.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$404.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$262.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$626.65
|
| Rate for Payer: PHCS Commercial |
$1,940.59
|
| Rate for Payer: United Healthcare All Payer |
$1,778.88
|
|
|
BX TONGUE
|
Facility
|
OP
|
$2,021.45
|
|
|
Service Code
|
HCPCS 41100
|
| Hospital Charge Code |
76101651
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$262.79 |
| Max. Negotiated Rate |
$1,940.59 |
| Rate for Payer: Aetna Commercial |
$1,556.52
|
| Rate for Payer: Anthem Medicaid |
$695.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,576.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$1,010.72
|
| Rate for Payer: Cash Price |
$1,010.72
|
| Rate for Payer: Cigna Commercial |
$1,677.80
|
| Rate for Payer: First Health Commercial |
$1,920.38
|
| Rate for Payer: Humana Commercial |
$1,718.23
|
| Rate for Payer: Humana KY Medicaid |
$695.18
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$702.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,657.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,491.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$709.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,778.88
|
| Rate for Payer: Ohio Health Group HMO |
$1,516.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$404.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$262.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$626.65
|
| Rate for Payer: PHCS Commercial |
$1,940.59
|
| Rate for Payer: United Healthcare All Payer |
$1,778.88
|
|
|
BX TONGUE(P
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS 41100
|
| Hospital Charge Code |
761P1651
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.04 |
| Max. Negotiated Rate |
$223.64 |
| Rate for Payer: Aetna Commercial |
$157.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$76.21
|
| Rate for Payer: Anthem Medicaid |
$59.04
|
| Rate for Payer: Buckeye Medicare Advantage |
$220.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$223.64
|
| Rate for Payer: Healthspan PPO |
$194.48
|
| Rate for Payer: Humana Medicaid |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$139.75
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.22
|
| Rate for Payer: Molina Healthcare Passport |
$59.04
|
| Rate for Payer: Multiplan PHCS |
$132.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.00
|
| Rate for Payer: UHCCP Medicaid |
$80.02
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$59.63
|
|
|
BX TONGUE(T
|
Facility
|
OP
|
$1,801.45
|
|
|
Service Code
|
HCPCS 41100
|
| Hospital Charge Code |
761T1651
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.19 |
| Max. Negotiated Rate |
$1,729.39 |
| Rate for Payer: Aetna Commercial |
$1,387.12
|
| Rate for Payer: Anthem Medicaid |
$619.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$475.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.13
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$666.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$642.32
|
| Rate for Payer: Cash Price |
$900.72
|
| Rate for Payer: Cash Price |
$900.72
|
| Rate for Payer: Cigna Commercial |
$1,495.20
|
| Rate for Payer: First Health Commercial |
$1,711.38
|
| Rate for Payer: Humana Commercial |
$1,531.23
|
| Rate for Payer: Humana KY Medicaid |
$619.52
|
| Rate for Payer: Humana Medicare Advantage |
$475.79
|
| Rate for Payer: Kentucky WC Medicaid |
$625.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$570.95
|
| Rate for Payer: Molina Healthcare Medicaid |
$631.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.45
|
| Rate for Payer: PHCS Commercial |
$1,729.39
|
| Rate for Payer: United Healthcare All Payer |
$1,585.28
|
|
|
BX TONGUE(T
|
Facility
|
IP
|
$1,801.45
|
|
|
Service Code
|
HCPCS 41100
|
| Hospital Charge Code |
761T1651
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$234.19 |
| Max. Negotiated Rate |
$1,729.39 |
| Rate for Payer: Aetna Commercial |
$1,387.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,405.13
|
| Rate for Payer: Cash Price |
$900.72
|
| Rate for Payer: Cigna Commercial |
$1,495.20
|
| Rate for Payer: First Health Commercial |
$1,711.38
|
| Rate for Payer: Humana Commercial |
$1,531.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,477.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,329.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$540.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,585.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,351.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$360.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$558.45
|
| Rate for Payer: PHCS Commercial |
$1,729.39
|
| Rate for Payer: United Healthcare All Payer |
$1,585.28
|
|
|
BYPASS GRAFT; COMPOSITE -
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 35681
|
| Hospital Charge Code |
76101416
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$109.94 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$144.05
|
| Rate for Payer: Anthem Medicaid |
$601.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$136.56
|
| Rate for Payer: Healthspan PPO |
$141.63
|
| Rate for Payer: Humana Medicaid |
$601.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$613.25
|
| Rate for Payer: Molina Healthcare Passport |
$601.23
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$607.24
|
|
|
BYPASS GRAFT; COMPOSITE -
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 35681
|
| Hospital Charge Code |
76101416
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem Medicaid |
$790.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Humana KY Medicaid |
$790.97
|
| Rate for Payer: Kentucky WC Medicaid |
$799.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
BYPASS GRAFT; COMPOSITE -
|
Facility
|
IP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 35681
|
| Hospital Charge Code |
76101416
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$299.00 |
| Max. Negotiated Rate |
$2,208.00 |
| Rate for Payer: Aetna Commercial |
$1,771.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,794.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$1,909.00
|
| Rate for Payer: First Health Commercial |
$2,185.00
|
| Rate for Payer: Humana Commercial |
$1,955.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,886.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,697.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$690.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,024.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,725.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$460.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$299.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$713.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
|
BYPASS GRAFT; COMPOSITE -(P
|
Professional
|
Both
|
$2,300.00
|
|
|
Service Code
|
HCPCS 35681
|
| Hospital Charge Code |
761P1416
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$109.94 |
| Max. Negotiated Rate |
$2,300.00 |
| Rate for Payer: Aetna Commercial |
$144.05
|
| Rate for Payer: Anthem Medicaid |
$601.23
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,300.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cash Price |
$1,150.00
|
| Rate for Payer: Cigna Commercial |
$136.56
|
| Rate for Payer: Healthspan PPO |
$141.63
|
| Rate for Payer: Humana Medicaid |
$601.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$613.25
|
| Rate for Payer: Molina Healthcare Passport |
$601.23
|
| Rate for Payer: Multiplan PHCS |
$1,380.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,610.00
|
| Rate for Payer: UHCCP Medicaid |
$805.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$607.24
|
|
|
BYPASS GRAFT - FEMORAL
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35661
|
| Hospital Charge Code |
76101413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| 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 |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
BYPASS GRAFT - FEMORAL
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35661
|
| Hospital Charge Code |
76101413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$832.01 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$1,920.83
|
| Rate for Payer: Anthem Medicaid |
$832.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,844.97
|
| Rate for Payer: Healthspan PPO |
$1,888.55
|
| Rate for Payer: Humana Medicaid |
$832.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,495.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$848.65
|
| Rate for Payer: Molina Healthcare Passport |
$832.01
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$840.33
|
|
|
BYPASS GRAFT - FEMORAL
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35661
|
| Hospital Charge Code |
76101413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$390.00 |
| 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 |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$390.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$930.00
|
| Rate for Payer: PHCS Commercial |
$2,880.00
|
| Rate for Payer: United Healthcare All Payer |
$2,640.00
|
|
|
BYPASS GRAFT - FEMORAL(P
|
Professional
|
Both
|
$3,000.00
|
|
|
Service Code
|
HCPCS 35661
|
| Hospital Charge Code |
761P1413
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$832.01 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna Commercial |
$1,920.83
|
| Rate for Payer: Anthem Medicaid |
$832.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,000.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cash Price |
$1,500.00
|
| Rate for Payer: Cigna Commercial |
$1,844.97
|
| Rate for Payer: Healthspan PPO |
$1,888.55
|
| Rate for Payer: Humana Medicaid |
$832.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,495.43
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$848.65
|
| Rate for Payer: Molina Healthcare Passport |
$832.01
|
| Rate for Payer: Multiplan PHCS |
$1,800.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,100.00
|
| Rate for Payer: UHCCP Medicaid |
$1,050.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$840.33
|
|
|
BYPASS GRAFT - FEMORAL POPLI(P
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35656
|
| Hospital Charge Code |
761P1412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$969.73 |
| Max. Negotiated Rate |
$3,200.00 |
| Rate for Payer: Aetna Commercial |
$1,922.54
|
| Rate for Payer: Anthem Medicaid |
$969.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,200.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$1,841.52
|
| Rate for Payer: Healthspan PPO |
$1,890.23
|
| Rate for Payer: Humana Medicaid |
$969.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,489.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$989.12
|
| Rate for Payer: Molina Healthcare Passport |
$969.73
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,240.00
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$979.43
|
|
|
BYPASS GRAFT - FEMORAL POPLIT
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35656
|
| Hospital Charge Code |
76101412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem Medicaid |
$1,100.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Humana KY Medicaid |
$1,100.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,111.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,122.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
BYPASS GRAFT - FEMORAL POPLIT
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35656
|
| Hospital Charge Code |
76101412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$416.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$416.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$992.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
BYPASS GRAFT - FEMORAL POPLIT
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35656
|
| Hospital Charge Code |
76101412
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$969.73 |
| Max. Negotiated Rate |
$3,200.00 |
| Rate for Payer: Aetna Commercial |
$1,922.54
|
| Rate for Payer: Anthem Medicaid |
$969.73
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,200.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$1,841.52
|
| Rate for Payer: Healthspan PPO |
$1,890.23
|
| Rate for Payer: Humana Medicaid |
$969.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,489.63
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$989.12
|
| Rate for Payer: Molina Healthcare Passport |
$969.73
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,240.00
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$979.43
|
|
|
BYPASS GRAFT PATENCY/PATCH
|
Professional
|
Both
|
$480.00
|
|
|
Service Code
|
HCPCS 35685
|
| Hospital Charge Code |
76101417
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$165.52 |
| Max. Negotiated Rate |
$480.00 |
| Rate for Payer: Aetna Commercial |
$361.25
|
| Rate for Payer: Anthem Medicaid |
$165.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$480.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$344.22
|
| Rate for Payer: Healthspan PPO |
$355.18
|
| Rate for Payer: Humana Medicaid |
$165.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$275.61
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$168.83
|
| Rate for Payer: Molina Healthcare Passport |
$165.52
|
| Rate for Payer: Multiplan PHCS |
$288.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$336.00
|
| Rate for Payer: UHCCP Medicaid |
$168.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$167.18
|
|
|
BYPASS GRAFT PATENCY/PATCH
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
HCPCS 35685
|
| Hospital Charge Code |
76101417
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$62.40 |
| Max. Negotiated Rate |
$460.80 |
| Rate for Payer: Aetna Commercial |
$369.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$374.40
|
| Rate for Payer: Cash Price |
$240.00
|
| Rate for Payer: Cigna Commercial |
$398.40
|
| Rate for Payer: First Health Commercial |
$456.00
|
| Rate for Payer: Humana Commercial |
$408.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$393.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$354.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$144.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$422.40
|
| Rate for Payer: Ohio Health Group HMO |
$360.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$148.80
|
| Rate for Payer: PHCS Commercial |
$460.80
|
| Rate for Payer: United Healthcare All Payer |
$422.40
|
|
