|
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
|
|
|
BYPASS GRAFT PATENCY/PATCH(P
|
Professional
|
Both
|
$480.00
|
|
|
Service Code
|
HCPCS 35685
|
| Hospital Charge Code |
761P1417
|
|
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 WITH VEIN
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35566
|
| Hospital Charge Code |
76101400
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,225.00 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,923.24
|
| Rate for Payer: Anthem Medicaid |
$1,245.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,500.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,759.22
|
| Rate for Payer: Healthspan PPO |
$2,874.12
|
| Rate for Payer: Humana Medicaid |
$1,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,304.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,270.14
|
| Rate for Payer: Molina Healthcare Passport |
$1,245.24
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,450.00
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,257.69
|
|
|
BYPASS GRAFT WITH VEIN
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35566
|
| Hospital Charge Code |
76101400
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,085.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
BYPASS GRAFT WITH VEIN
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35566
|
| Hospital Charge Code |
76101400
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,085.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
BYPASS GRAFT - WITH VEIN; AO(P
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35560
|
| Hospital Charge Code |
761P1398
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,225.00 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$3,160.54
|
| Rate for Payer: Anthem Medicaid |
$1,286.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,500.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$3,008.68
|
| Rate for Payer: Healthspan PPO |
$3,107.43
|
| Rate for Payer: Humana Medicaid |
$1,286.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,402.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,312.65
|
| Rate for Payer: Molina Healthcare Passport |
$1,286.91
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,450.00
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,299.78
|
|
|
BYPASS GRAFT - WITH VEIN; AOR
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35560
|
| Hospital Charge Code |
76101398
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,085.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
BYPASS GRAFT - WITH VEIN; AOR
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35560
|
| Hospital Charge Code |
76101398
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,085.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
BYPASS GRAFT - WITH VEIN; AOR
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35560
|
| Hospital Charge Code |
76101398
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,225.00 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$3,160.54
|
| Rate for Payer: Anthem Medicaid |
$1,286.91
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,500.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$3,008.68
|
| Rate for Payer: Healthspan PPO |
$3,107.43
|
| Rate for Payer: Humana Medicaid |
$1,286.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,402.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,312.65
|
| Rate for Payer: Molina Healthcare Passport |
$1,286.91
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,450.00
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,299.78
|
|
|
BYPASS GRAFT - WITH VEIN; ILI
|
Facility
|
IP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35565
|
| Hospital Charge Code |
76101399
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,085.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
BYPASS GRAFT - WITH VEIN; ILI
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35565
|
| Hospital Charge Code |
76101399
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$965.59 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,337.48
|
| Rate for Payer: Anthem Medicaid |
$965.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,500.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,227.93
|
| Rate for Payer: Healthspan PPO |
$2,298.20
|
| Rate for Payer: Humana Medicaid |
$965.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,815.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$984.90
|
| Rate for Payer: Molina Healthcare Passport |
$965.59
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,450.00
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$975.25
|
|
|
BYPASS GRAFT - WITH VEIN; ILI
|
Facility
|
OP
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35565
|
| Hospital Charge Code |
76101399
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$455.00 |
| Max. Negotiated Rate |
$3,360.00 |
| Rate for Payer: Aetna Commercial |
$2,695.00
|
| Rate for Payer: Anthem Medicaid |
$1,203.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,730.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,905.00
|
| Rate for Payer: First Health Commercial |
$3,325.00
|
| Rate for Payer: Humana Commercial |
$2,975.00
|
| Rate for Payer: Humana KY Medicaid |
$1,203.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1,215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,870.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,583.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,050.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,227.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,080.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$455.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,085.00
|
| Rate for Payer: PHCS Commercial |
$3,360.00
|
| Rate for Payer: United Healthcare All Payer |
$3,080.00
|
|
|
BYPASS GRAFT - WITH VEIN; IL(P
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35565
|
| Hospital Charge Code |
761P1399
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$965.59 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,337.48
|
| Rate for Payer: Anthem Medicaid |
$965.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,500.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,227.93
|
| Rate for Payer: Healthspan PPO |
$2,298.20
|
| Rate for Payer: Humana Medicaid |
$965.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,815.51
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$984.90
|
| Rate for Payer: Molina Healthcare Passport |
$965.59
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,450.00
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$975.25
|
|
|
BYPASS GRAFT WITH VEIN(P
|
Professional
|
Both
|
$3,500.00
|
|
|
Service Code
|
HCPCS 35566
|
| Hospital Charge Code |
761P1400
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,225.00 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$2,923.24
|
| Rate for Payer: Anthem Medicaid |
$1,245.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,500.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cigna Commercial |
$2,759.22
|
| Rate for Payer: Healthspan PPO |
$2,874.12
|
| Rate for Payer: Humana Medicaid |
$1,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,304.69
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,270.14
|
| Rate for Payer: Molina Healthcare Passport |
$1,245.24
|
| Rate for Payer: Multiplan PHCS |
$2,100.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,450.00
|
| Rate for Payer: UHCCP Medicaid |
$1,225.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,257.69
|
|
|
BYSTOLIC 10MG TABLET
|
Facility
|
OP
|
$11.50
|
|
|
Service Code
|
NDC 60687065221
|
| Hospital Charge Code |
25000358
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Anthem Medicaid |
$3.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.97
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Cigna Commercial |
$9.54
|
| Rate for Payer: First Health Commercial |
$10.92
|
| Rate for Payer: Humana Commercial |
$9.78
|
| Rate for Payer: Humana KY Medicaid |
$3.95
|
| Rate for Payer: Kentucky WC Medicaid |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.12
|
| Rate for Payer: Ohio Health Group HMO |
$8.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.56
|
| Rate for Payer: PHCS Commercial |
$11.04
|
| Rate for Payer: United Healthcare All Payer |
$10.12
|
| Rate for Payer: Aetna Commercial |
$8.86
|
|
|
BYSTOLIC 10MG TABLET
|
Facility
|
IP
|
$11.50
|
|
|
Service Code
|
NDC 60687065221
|
| Hospital Charge Code |
25000358
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$11.04 |
| Rate for Payer: Aetna Commercial |
$8.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.97
|
| Rate for Payer: Cash Price |
$5.75
|
| Rate for Payer: Cigna Commercial |
$9.54
|
| Rate for Payer: First Health Commercial |
$10.92
|
| Rate for Payer: Humana Commercial |
$9.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.12
|
| Rate for Payer: Ohio Health Group HMO |
$8.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.56
|
| Rate for Payer: PHCS Commercial |
$11.04
|
| Rate for Payer: United Healthcare All Payer |
$10.12
|
|
|
BYSTOLIC 5MG TABLET
|
Facility
|
OP
|
$4.42
|
|
|
Service Code
|
NDC 43547052509
|
| Hospital Charge Code |
25000359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
BYSTOLIC 5MG TABLET
|
Facility
|
IP
|
$4.42
|
|
|
Service Code
|
NDC 43547052509
|
| Hospital Charge Code |
25000359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Cash Price |
$2.21
|
| Rate for Payer: Cigna Commercial |
$3.67
|
| Rate for Payer: First Health Commercial |
$4.20
|
| Rate for Payer: Humana Commercial |
$3.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.89
|
| Rate for Payer: Ohio Health Group HMO |
$3.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.24
|
| Rate for Payer: United Healthcare All Payer |
$3.89
|
|
|
C1 GLIDECATH 4FR 65CM
|
Facility
|
IP
|
$818.48
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.40 |
| Max. Negotiated Rate |
$785.74 |
| Rate for Payer: Aetna Commercial |
$630.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$638.41
|
| Rate for Payer: Cash Price |
$409.24
|
| Rate for Payer: Cigna Commercial |
$679.34
|
| Rate for Payer: First Health Commercial |
$777.56
|
| Rate for Payer: Humana Commercial |
$695.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$671.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$604.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$720.26
|
| Rate for Payer: Ohio Health Group HMO |
$613.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$253.73
|
| Rate for Payer: PHCS Commercial |
$785.74
|
| Rate for Payer: United Healthcare All Payer |
$720.26
|
|
|
C1 GLIDECATH 4FR 65CM
|
Facility
|
OP
|
$818.48
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.40 |
| Max. Negotiated Rate |
$785.74 |
| Rate for Payer: Aetna Commercial |
$630.23
|
| Rate for Payer: Anthem Medicaid |
$281.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$638.41
|
| Rate for Payer: Cash Price |
$409.24
|
| Rate for Payer: Cigna Commercial |
$679.34
|
| Rate for Payer: First Health Commercial |
$777.56
|
| Rate for Payer: Humana Commercial |
$695.71
|
| Rate for Payer: Humana KY Medicaid |
$281.48
|
| Rate for Payer: Kentucky WC Medicaid |
$284.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$671.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$604.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$287.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$720.26
|
| Rate for Payer: Ohio Health Group HMO |
$613.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$253.73
|
| Rate for Payer: PHCS Commercial |
$785.74
|
| Rate for Payer: United Healthcare All Payer |
$720.26
|
|
|
C2 GLIDECATH 4FR 65CM
|
Facility
|
IP
|
$818.48
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.40 |
| Max. Negotiated Rate |
$785.74 |
| Rate for Payer: Aetna Commercial |
$630.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$638.41
|
| Rate for Payer: Cash Price |
$409.24
|
| Rate for Payer: Cigna Commercial |
$679.34
|
| Rate for Payer: First Health Commercial |
$777.56
|
| Rate for Payer: Humana Commercial |
$695.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$671.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$604.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$720.26
|
| Rate for Payer: Ohio Health Group HMO |
$613.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$253.73
|
| Rate for Payer: PHCS Commercial |
$785.74
|
| Rate for Payer: United Healthcare All Payer |
$720.26
|
|
|
C2 GLIDECATH 4FR 65CM
|
Facility
|
OP
|
$818.48
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.40 |
| Max. Negotiated Rate |
$785.74 |
| Rate for Payer: Aetna Commercial |
$630.23
|
| Rate for Payer: Anthem Medicaid |
$281.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$638.41
|
| Rate for Payer: Cash Price |
$409.24
|
| Rate for Payer: Cigna Commercial |
$679.34
|
| Rate for Payer: First Health Commercial |
$777.56
|
| Rate for Payer: Humana Commercial |
$695.71
|
| Rate for Payer: Humana KY Medicaid |
$281.48
|
| Rate for Payer: Kentucky WC Medicaid |
$284.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$671.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$604.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$245.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$287.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$720.26
|
| Rate for Payer: Ohio Health Group HMO |
$613.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$253.73
|
| Rate for Payer: PHCS Commercial |
$785.74
|
| Rate for Payer: United Healthcare All Payer |
$720.26
|
|
|
C2 KIT 3.0 * 12
|
Facility
|
OP
|
$21,955.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,854.15 |
| Max. Negotiated Rate |
$21,076.80 |
| Rate for Payer: Aetna Commercial |
$16,905.35
|
| Rate for Payer: Anthem Medicaid |
$7,550.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,124.90
|
| Rate for Payer: Cash Price |
$10,977.50
|
| Rate for Payer: Cigna Commercial |
$18,222.65
|
| Rate for Payer: First Health Commercial |
$20,857.25
|
| Rate for Payer: Humana Commercial |
$18,661.75
|
| Rate for Payer: Humana KY Medicaid |
$7,550.32
|
| Rate for Payer: Kentucky WC Medicaid |
$7,627.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,003.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,202.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,586.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,701.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,320.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,466.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,391.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,854.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,806.05
|
| Rate for Payer: PHCS Commercial |
$21,076.80
|
| Rate for Payer: United Healthcare All Payer |
$19,320.40
|
|
|
C2 KIT 3.0 * 12
|
Facility
|
IP
|
$21,955.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,854.15 |
| Max. Negotiated Rate |
$21,076.80 |
| Rate for Payer: Aetna Commercial |
$16,905.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,124.90
|
| Rate for Payer: Cash Price |
$10,977.50
|
| Rate for Payer: Cigna Commercial |
$18,222.65
|
| Rate for Payer: First Health Commercial |
$20,857.25
|
| Rate for Payer: Humana Commercial |
$18,661.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,003.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,202.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,586.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,320.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,466.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,391.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,854.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,806.05
|
| Rate for Payer: PHCS Commercial |
$21,076.80
|
| Rate for Payer: United Healthcare All Payer |
$19,320.40
|
|
|
C2 KIT 3.5*12
|
Facility
|
OP
|
$21,955.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,854.15 |
| Max. Negotiated Rate |
$21,076.80 |
| Rate for Payer: Aetna Commercial |
$16,905.35
|
| Rate for Payer: Anthem Medicaid |
$7,550.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,124.90
|
| Rate for Payer: Cash Price |
$10,977.50
|
| Rate for Payer: Cigna Commercial |
$18,222.65
|
| Rate for Payer: First Health Commercial |
$20,857.25
|
| Rate for Payer: Humana Commercial |
$18,661.75
|
| Rate for Payer: Humana KY Medicaid |
$7,550.32
|
| Rate for Payer: Kentucky WC Medicaid |
$7,627.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,003.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,202.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,586.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,701.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,320.40
|
| Rate for Payer: Ohio Health Group HMO |
$16,466.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,391.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,854.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,806.05
|
| Rate for Payer: PHCS Commercial |
$21,076.80
|
| Rate for Payer: United Healthcare All Payer |
$19,320.40
|
|
