|
CESSJ THERAPY CATH REMOVAL
|
Facility
|
IP
|
$5,443.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
76101539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$707.59 |
| Max. Negotiated Rate |
$5,225.28 |
| Rate for Payer: Aetna Commercial |
$4,191.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,245.54
|
| Rate for Payer: Cash Price |
$2,721.50
|
| Rate for Payer: Cigna Commercial |
$4,517.69
|
| Rate for Payer: First Health Commercial |
$5,170.85
|
| Rate for Payer: Humana Commercial |
$4,626.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,463.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,016.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,632.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,789.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,082.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,088.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.33
|
| Rate for Payer: PHCS Commercial |
$5,225.28
|
| Rate for Payer: United Healthcare All Payer |
$4,789.84
|
|
|
CESSJ THERAPY CATH REMOVAL(P
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
761P1539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$118.33 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Anthem Medicaid |
$118.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$500.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cash Price |
$250.00
|
| Rate for Payer: Cigna Commercial |
$273.65
|
| Rate for Payer: Healthspan PPO |
$139.48
|
| Rate for Payer: Humana Medicaid |
$118.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$185.50
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$120.70
|
| Rate for Payer: Molina Healthcare Passport |
$118.33
|
| Rate for Payer: Multiplan PHCS |
$300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$350.00
|
| Rate for Payer: UHCCP Medicaid |
$175.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$119.51
|
|
|
CESSJ THERAPY CATH REMOVAL(T
|
Facility
|
IP
|
$4,943.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
761T1539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$642.59 |
| Max. Negotiated Rate |
$4,745.28 |
| Rate for Payer: Aetna Commercial |
$3,806.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,855.54
|
| Rate for Payer: Cash Price |
$2,471.50
|
| Rate for Payer: Cigna Commercial |
$4,102.69
|
| Rate for Payer: First Health Commercial |
$4,695.85
|
| Rate for Payer: Humana Commercial |
$4,201.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,053.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,647.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,482.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,349.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,707.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,532.33
|
| Rate for Payer: PHCS Commercial |
$4,745.28
|
| Rate for Payer: United Healthcare All Payer |
$4,349.84
|
|
|
CESSJ THERAPY CATH REMOVAL(T
|
Facility
|
OP
|
$4,943.00
|
|
|
Service Code
|
HCPCS 37214
|
| Hospital Charge Code |
761T1539
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$642.59 |
| Max. Negotiated Rate |
$4,745.28 |
| Rate for Payer: Aetna Commercial |
$3,806.11
|
| Rate for Payer: Anthem Medicaid |
$1,699.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,756.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,855.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,858.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,721.13
|
| Rate for Payer: Cash Price |
$2,471.50
|
| Rate for Payer: Cash Price |
$2,471.50
|
| Rate for Payer: Cigna Commercial |
$4,102.69
|
| Rate for Payer: First Health Commercial |
$4,695.85
|
| Rate for Payer: Humana Commercial |
$4,201.55
|
| Rate for Payer: Humana KY Medicaid |
$1,699.90
|
| Rate for Payer: Humana Medicare Advantage |
$2,756.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,717.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,053.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,647.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,734.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,349.84
|
| Rate for Payer: Ohio Health Group HMO |
$3,707.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$988.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$642.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,532.33
|
| Rate for Payer: PHCS Commercial |
$4,745.28
|
| Rate for Payer: United Healthcare All Payer |
$4,349.84
|
|
|
CETACAINE (UD) SPRY (20GM KIT)
|
Facility
|
OP
|
$14.45
|
|
|
Service Code
|
NDC 10223020103
|
| Hospital Charge Code |
25002936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$11.13
|
| Rate for Payer: Anthem Medicaid |
$4.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11.27
|
| Rate for Payer: Cash Price |
$7.22
|
| Rate for Payer: Cigna Commercial |
$11.99
|
| Rate for Payer: First Health Commercial |
$13.73
|
| Rate for Payer: Humana Commercial |
$12.28
|
| Rate for Payer: Humana KY Medicaid |
$4.97
|
| Rate for Payer: Kentucky WC Medicaid |
$5.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.72
|
| Rate for Payer: Ohio Health Group HMO |
$10.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.48
|
| Rate for Payer: PHCS Commercial |
$13.87
|
| Rate for Payer: United Healthcare All Payer |
$12.72
|
|
|
CETACAINE (UD) SPRY (20GM KIT)
|
Facility
|
IP
|
$14.45
|
|
|
Service Code
|
NDC 10223020103
|
| Hospital Charge Code |
25002936
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$13.87 |
| Rate for Payer: Aetna Commercial |
$11.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11.27
|
| Rate for Payer: Cash Price |
$7.22
|
| Rate for Payer: Cigna Commercial |
$11.99
|
| Rate for Payer: First Health Commercial |
$13.73
|
| Rate for Payer: Humana Commercial |
$12.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$12.72
|
| Rate for Payer: Ohio Health Group HMO |
$10.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4.48
|
| Rate for Payer: PHCS Commercial |
$13.87
|
| Rate for Payer: United Healthcare All Payer |
$12.72
|
|
|
[C]FIORINAL (COMBINATION) 1TAB
|
Facility
|
OP
|
$9.10
|
|
|
Service Code
|
NDC 527155201
|
| Hospital Charge Code |
25000098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem Medicaid |
$3.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Humana KY Medicaid |
$3.13
|
| Rate for Payer: Kentucky WC Medicaid |
$3.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
|
[C]FIORINAL (COMBINATION) 1TAB
|
Facility
|
IP
|
$9.10
|
|
|
Service Code
|
NDC 527155201
|
| Hospital Charge Code |
25000098
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$8.74 |
| Rate for Payer: Aetna Commercial |
$7.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Cash Price |
$4.55
|
| Rate for Payer: Cigna Commercial |
$7.55
|
| Rate for Payer: First Health Commercial |
$8.64
|
| Rate for Payer: Humana Commercial |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.01
|
| Rate for Payer: Ohio Health Group HMO |
$6.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.82
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.82
|
| Rate for Payer: PHCS Commercial |
$8.74
|
| Rate for Payer: United Healthcare All Payer |
$8.01
|
|
|
[C]FIORINAL W/CODEINE #3 1CAP
|
Facility
|
IP
|
$10.19
|
|
|
Service Code
|
NDC 69238199301
|
| Hospital Charge Code |
25000099
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.95
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.46
|
| Rate for Payer: First Health Commercial |
$9.68
|
| Rate for Payer: Humana Commercial |
$8.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.97
|
| Rate for Payer: Ohio Health Group HMO |
$7.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Payer |
$8.97
|
|
|
[C]FIORINAL W/CODEINE #3 1CAP
|
Facility
|
OP
|
$10.19
|
|
|
Service Code
|
NDC 69238199301
|
| Hospital Charge Code |
25000099
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$9.78 |
| Rate for Payer: Aetna Commercial |
$7.85
|
| Rate for Payer: Anthem Medicaid |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.95
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna Commercial |
$8.46
|
| Rate for Payer: First Health Commercial |
$9.68
|
| Rate for Payer: Humana Commercial |
$8.66
|
| Rate for Payer: Humana KY Medicaid |
$3.50
|
| Rate for Payer: Kentucky WC Medicaid |
$3.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.97
|
| Rate for Payer: Ohio Health Group HMO |
$7.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.16
|
| Rate for Payer: PHCS Commercial |
$9.78
|
| Rate for Payer: United Healthcare All Payer |
$8.97
|
|
|
CG FUTURE BAND MODEL 638B 30MM
|
Facility
|
IP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 30MM
|
Facility
|
OP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem Medicaid |
$4,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Humana KY Medicaid |
$4,072.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,113.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,153.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 32MM
|
Facility
|
OP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem Medicaid |
$4,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Humana KY Medicaid |
$4,072.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,113.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,153.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 32MM
|
Facility
|
IP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 34MM
|
Facility
|
IP
|
$12,790.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.70 |
| Max. Negotiated Rate |
$12,278.40 |
| Rate for Payer: Aetna Commercial |
$9,848.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,976.20
|
| Rate for Payer: Cash Price |
$6,395.00
|
| Rate for Payer: Cigna Commercial |
$10,615.70
|
| Rate for Payer: First Health Commercial |
$12,150.50
|
| Rate for Payer: Humana Commercial |
$10,871.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,487.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,439.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,837.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,255.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,558.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.90
|
| Rate for Payer: PHCS Commercial |
$12,278.40
|
| Rate for Payer: United Healthcare All Payer |
$11,255.20
|
|
|
CG FUTURE BAND MODEL 638B 34MM
|
Facility
|
OP
|
$12,790.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.70 |
| Max. Negotiated Rate |
$12,278.40 |
| Rate for Payer: Aetna Commercial |
$9,848.30
|
| Rate for Payer: Anthem Medicaid |
$4,398.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,976.20
|
| Rate for Payer: Cash Price |
$6,395.00
|
| Rate for Payer: Cigna Commercial |
$10,615.70
|
| Rate for Payer: First Health Commercial |
$12,150.50
|
| Rate for Payer: Humana Commercial |
$10,871.50
|
| Rate for Payer: Humana KY Medicaid |
$4,398.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,443.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,487.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,439.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,837.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,486.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,255.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,558.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.90
|
| Rate for Payer: PHCS Commercial |
$12,278.40
|
| Rate for Payer: United Healthcare All Payer |
$11,255.20
|
|
|
CG FUTURE BAND MODEL 638B 36MM
|
Facility
|
OP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem Medicaid |
$4,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Humana KY Medicaid |
$4,072.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,113.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,153.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 36MM
|
Facility
|
IP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 38MM
|
Facility
|
OP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem Medicaid |
$4,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Humana KY Medicaid |
$4,072.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,113.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,153.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE BAND MODEL 638B 38MM
|
Facility
|
IP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE VALVE BAND 26MM
|
Facility
|
OP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem Medicaid |
$4,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Humana KY Medicaid |
$4,072.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,113.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,153.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE VALVE BAND 26MM
|
Facility
|
IP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE VALVE BAND MODEL28MM
|
Facility
|
OP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem Medicaid |
$4,072.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Humana KY Medicaid |
$4,072.12
|
| Rate for Payer: Kentucky WC Medicaid |
$4,113.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,153.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
CG FUTURE VALVE BAND MODEL28MM
|
Facility
|
IP
|
$11,841.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,539.33 |
| Max. Negotiated Rate |
$11,367.36 |
| Rate for Payer: Aetna Commercial |
$9,117.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,235.98
|
| Rate for Payer: Cash Price |
$5,920.50
|
| Rate for Payer: Cigna Commercial |
$9,828.03
|
| Rate for Payer: First Health Commercial |
$11,248.95
|
| Rate for Payer: Humana Commercial |
$10,064.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,709.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,738.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,552.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,420.08
|
| Rate for Payer: Ohio Health Group HMO |
$8,880.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,368.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,539.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,670.71
|
| Rate for Payer: PHCS Commercial |
$11,367.36
|
| Rate for Payer: United Healthcare All Payer |
$10,420.08
|
|
|
[C]GUAIF/COD 5ML PO
|
Facility
|
OP
|
$60.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$57.93 |
| Rate for Payer: Aetna Commercial |
$46.46
|
| Rate for Payer: Anthem Medicaid |
$20.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.07
|
| Rate for Payer: Cash Price |
$30.17
|
| Rate for Payer: Cigna Commercial |
$50.08
|
| Rate for Payer: First Health Commercial |
$57.32
|
| Rate for Payer: Humana Commercial |
$51.29
|
| Rate for Payer: Humana KY Medicaid |
$20.75
|
| Rate for Payer: Kentucky WC Medicaid |
$20.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.10
|
| Rate for Payer: Ohio Health Group HMO |
$45.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.71
|
| Rate for Payer: PHCS Commercial |
$57.93
|
| Rate for Payer: United Healthcare All Payer |
$53.10
|
|
