|
C2 GLIDECATH 4FR 65CM
|
Facility
|
IP
|
$842.75
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.82 |
| Max. Negotiated Rate |
$809.04 |
| Rate for Payer: Aetna Commercial |
$648.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$657.35
|
| Rate for Payer: Cash Price |
$421.38
|
| Rate for Payer: Cigna Commercial |
$699.48
|
| Rate for Payer: First Health Commercial |
$800.61
|
| Rate for Payer: Humana Commercial |
$716.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$691.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$741.62
|
| Rate for Payer: Ohio Health Group HMO |
$632.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$674.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$733.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.50
|
| Rate for Payer: PHCS Commercial |
$809.04
|
| Rate for Payer: United Healthcare All Payer |
$741.62
|
|
|
C2 GLIDECATH 4FR 65CM
|
Facility
|
OP
|
$842.75
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$252.82 |
| Max. Negotiated Rate |
$809.04 |
| Rate for Payer: Aetna Commercial |
$648.92
|
| Rate for Payer: Anthem Medicaid |
$289.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$657.35
|
| Rate for Payer: Cash Price |
$421.38
|
| Rate for Payer: Cigna Commercial |
$699.48
|
| Rate for Payer: First Health Commercial |
$800.61
|
| Rate for Payer: Humana Commercial |
$716.34
|
| Rate for Payer: Humana KY Medicaid |
$289.82
|
| Rate for Payer: Kentucky WC Medicaid |
$292.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$691.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$621.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$295.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$741.62
|
| Rate for Payer: Ohio Health Group HMO |
$632.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$674.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$733.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.50
|
| Rate for Payer: PHCS Commercial |
$809.04
|
| Rate for Payer: United Healthcare All Payer |
$741.62
|
|
|
C2 KIT 2.5 * 12
|
Facility
|
IP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 2.5 * 12
|
Facility
|
OP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem Medicaid |
$7,780.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Humana KY Medicaid |
$7,780.74
|
| Rate for Payer: Kentucky WC Medicaid |
$7,859.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,936.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 3.0 * 12
|
Facility
|
IP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 3.0 * 12
|
Facility
|
OP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem Medicaid |
$7,780.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Humana KY Medicaid |
$7,780.74
|
| Rate for Payer: Kentucky WC Medicaid |
$7,859.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,936.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 3.5*12
|
Facility
|
IP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 3.5*12
|
Facility
|
OP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem Medicaid |
$7,780.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Humana KY Medicaid |
$7,780.74
|
| Rate for Payer: Kentucky WC Medicaid |
$7,859.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,936.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 4.0 * 12
|
Facility
|
IP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
C2 KIT 4.0 * 12
|
Facility
|
OP
|
$22,625.00
|
|
|
Service Code
|
HCPCS C1761
|
| Hospital Charge Code |
27000275
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,787.50 |
| Max. Negotiated Rate |
$21,720.00 |
| Rate for Payer: Aetna Commercial |
$17,421.25
|
| Rate for Payer: Anthem Medicaid |
$7,780.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,647.50
|
| Rate for Payer: Cash Price |
$11,312.50
|
| Rate for Payer: Cigna Commercial |
$18,778.75
|
| Rate for Payer: First Health Commercial |
$21,493.75
|
| Rate for Payer: Humana Commercial |
$19,231.25
|
| Rate for Payer: Humana KY Medicaid |
$7,780.74
|
| Rate for Payer: Kentucky WC Medicaid |
$7,859.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,552.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,697.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,787.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,936.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,910.00
|
| Rate for Payer: Ohio Health Group HMO |
$16,968.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$19,683.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15,611.25
|
| Rate for Payer: PHCS Commercial |
$21,720.00
|
| Rate for Payer: United Healthcare All Payer |
$19,910.00
|
|
|
CABENUVA (2/3MG)600/900MG KIT
|
Facility
|
IP
|
$8,539.26
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
25004558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,561.78 |
| Max. Negotiated Rate |
$8,197.69 |
| Rate for Payer: Aetna Commercial |
$6,575.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,660.62
|
| Rate for Payer: Cash Price |
$4,269.63
|
| Rate for Payer: Cigna Commercial |
$7,087.59
|
| Rate for Payer: First Health Commercial |
$8,112.30
|
| Rate for Payer: Humana Commercial |
$7,258.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,002.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,301.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,561.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,514.55
|
| Rate for Payer: Ohio Health Group HMO |
$6,404.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,831.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,429.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,892.09
|
| Rate for Payer: PHCS Commercial |
$8,197.69
|
| Rate for Payer: United Healthcare All Payer |
$7,514.55
|
|
|
CABENUVA (2/3MG)600/900MG KIT
|
Facility
|
OP
|
$8,539.26
|
|
|
Service Code
|
HCPCS J0741
|
| Hospital Charge Code |
25004558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.63 |
| Max. Negotiated Rate |
$8,197.69 |
| Rate for Payer: Aetna Commercial |
$6,575.23
|
| Rate for Payer: Anthem Medicaid |
$2,936.65
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$23.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,660.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$33.08
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.90
|
| Rate for Payer: Cash Price |
$4,269.63
|
| Rate for Payer: Cash Price |
$4,269.63
|
| Rate for Payer: Cigna Commercial |
$7,087.59
|
| Rate for Payer: First Health Commercial |
$8,112.30
|
| Rate for Payer: Humana Commercial |
$7,258.37
|
| Rate for Payer: Humana KY Medicaid |
$2,936.65
|
| Rate for Payer: Humana Medicare Advantage |
$23.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,966.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,002.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,301.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,995.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,514.55
|
| Rate for Payer: Ohio Health Group HMO |
$6,404.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,831.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,429.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,892.09
|
| Rate for Payer: PHCS Commercial |
$8,197.69
|
| Rate for Payer: United Healthcare All Payer |
$7,514.55
|
|
|
CABG ART SINGLE
|
Facility
|
OP
|
$5,500.00
|
|
|
Service Code
|
HCPCS 33533
|
| Hospital Charge Code |
76101308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,650.00 |
| Max. Negotiated Rate |
$5,280.00 |
| Rate for Payer: Aetna Commercial |
$4,235.00
|
| Rate for Payer: Anthem Medicaid |
$1,891.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,290.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$4,565.00
|
| Rate for Payer: First Health Commercial |
$5,225.00
|
| Rate for Payer: Humana Commercial |
$4,675.00
|
| Rate for Payer: Humana KY Medicaid |
$1,891.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,910.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,510.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,059.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,929.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,840.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,785.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,795.00
|
| Rate for Payer: PHCS Commercial |
$5,280.00
|
| Rate for Payer: United Healthcare All Payer |
$4,840.00
|
|
|
CABG ART SINGLE
|
Facility
|
IP
|
$5,500.00
|
|
|
Service Code
|
HCPCS 33533
|
| Hospital Charge Code |
76101308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,650.00 |
| Max. Negotiated Rate |
$5,280.00 |
| Rate for Payer: Aetna Commercial |
$4,235.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,290.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$4,565.00
|
| Rate for Payer: First Health Commercial |
$5,225.00
|
| Rate for Payer: Humana Commercial |
$4,675.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,510.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,059.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,840.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,785.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,795.00
|
| Rate for Payer: PHCS Commercial |
$5,280.00
|
| Rate for Payer: United Healthcare All Payer |
$4,840.00
|
|
|
CABG ART SINGLE
|
Professional
|
Both
|
$5,500.00
|
|
|
Service Code
|
HCPCS 33533
|
| Hospital Charge Code |
76101308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,651.21 |
| Max. Negotiated Rate |
$3,300.00 |
| Rate for Payer: Aetna Commercial |
$3,272.51
|
| Rate for Payer: Ambetter Exchange |
$1,758.67
|
| Rate for Payer: Anthem Medicaid |
$1,651.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,758.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,758.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,110.40
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$3,154.84
|
| Rate for Payer: Healthspan PPO |
$3,217.52
|
| Rate for Payer: Humana Medicaid |
$1,651.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,671.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,758.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,758.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,684.23
|
| Rate for Payer: Molina Healthcare Passport |
$1,651.21
|
| Rate for Payer: Multiplan PHCS |
$3,300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,286.27
|
| Rate for Payer: UHCCP Medicaid |
$1,925.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,667.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,758.67
|
|
|
CABG ART SINGLE(P
|
Professional
|
Both
|
$5,500.00
|
|
|
Service Code
|
HCPCS 33533
|
| Hospital Charge Code |
761P1308
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,651.21 |
| Max. Negotiated Rate |
$3,300.00 |
| Rate for Payer: Aetna Commercial |
$3,272.51
|
| Rate for Payer: Ambetter Exchange |
$1,758.67
|
| Rate for Payer: Anthem Medicaid |
$1,651.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,758.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,758.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,110.40
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cash Price |
$2,750.00
|
| Rate for Payer: Cigna Commercial |
$3,154.84
|
| Rate for Payer: Healthspan PPO |
$3,217.52
|
| Rate for Payer: Humana Medicaid |
$1,651.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,671.73
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,758.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,758.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,684.23
|
| Rate for Payer: Molina Healthcare Passport |
$1,651.21
|
| Rate for Payer: Multiplan PHCS |
$3,300.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,286.27
|
| Rate for Payer: UHCCP Medicaid |
$1,925.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,667.72
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,758.67
|
|
|
CABG ART VEIN 2
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33518
|
| Hospital Charge Code |
76101302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
CABG ART VEIN 2
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33518
|
| Hospital Charge Code |
76101302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$313.06 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$685.88
|
| Rate for Payer: Ambetter Exchange |
$385.71
|
| Rate for Payer: Anthem Medicaid |
$313.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$385.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$385.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$462.85
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$609.83
|
| Rate for Payer: Healthspan PPO |
$674.36
|
| Rate for Payer: Humana Medicaid |
$313.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$584.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$385.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$385.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$319.32
|
| Rate for Payer: Molina Healthcare Passport |
$313.06
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$501.42
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$316.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$385.71
|
|
|
CABG ART VEIN 2
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33518
|
| Hospital Charge Code |
76101302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
CABG ART VEIN 2(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33518
|
| Hospital Charge Code |
761P1302
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$313.06 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$685.88
|
| Rate for Payer: Ambetter Exchange |
$385.71
|
| Rate for Payer: Anthem Medicaid |
$313.06
|
| Rate for Payer: Buckeye Individual/Medicaid |
$385.71
|
| Rate for Payer: Buckeye Medicare Advantage |
$385.71
|
| Rate for Payer: CareSource Just4Me Medicare |
$462.85
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$609.83
|
| Rate for Payer: Healthspan PPO |
$674.36
|
| Rate for Payer: Humana Medicaid |
$313.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$584.61
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$385.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$385.71
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$319.32
|
| Rate for Payer: Molina Healthcare Passport |
$313.06
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$501.42
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$316.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$385.71
|
|
|
CABG ART VEIN 3
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 33519
|
| Hospital Charge Code |
76101303
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.07 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$917.33
|
| Rate for Payer: Ambetter Exchange |
$508.82
|
| Rate for Payer: Anthem Medicaid |
$469.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$508.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$508.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$610.58
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$821.46
|
| Rate for Payer: Healthspan PPO |
$901.90
|
| Rate for Payer: Humana Medicaid |
$469.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$774.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$508.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$508.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$478.45
|
| Rate for Payer: Molina Healthcare Passport |
$469.07
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$661.47
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$473.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$508.82
|
|
|
CABG ART VEIN 3
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 33519
|
| Hospital Charge Code |
76101303
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Humana KY Medicaid |
$859.75
|
| Rate for Payer: Kentucky WC Medicaid |
$868.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
CABG ART VEIN 3
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 33519
|
| Hospital Charge Code |
76101303
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
CABG ART VEIN 3(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 33519
|
| Hospital Charge Code |
761P1303
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$469.07 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$917.33
|
| Rate for Payer: Ambetter Exchange |
$508.82
|
| Rate for Payer: Anthem Medicaid |
$469.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$508.82
|
| Rate for Payer: Buckeye Medicare Advantage |
$508.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$610.58
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$821.46
|
| Rate for Payer: Healthspan PPO |
$901.90
|
| Rate for Payer: Humana Medicaid |
$469.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$774.70
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$508.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$508.82
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$478.45
|
| Rate for Payer: Molina Healthcare Passport |
$469.07
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$661.47
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$473.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$508.82
|
|
|
CABG ART-VEIN SIX OR MORE
|
Facility
|
OP
|
$2,300.00
|
|
|
Service Code
|
HCPCS 33523
|
| Hospital Charge Code |
76101306
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$690.00 |
| 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 |
$1,840.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,001.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,587.00
|
| Rate for Payer: PHCS Commercial |
$2,208.00
|
| Rate for Payer: United Healthcare All Payer |
$2,024.00
|
|
