|
CG FUTURE BAND MODEL 638B 36MM
|
Facility
|
OP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem Medicaid |
$4,156.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Humana KY Medicaid |
$4,156.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE BAND MODEL 638B 38MM
|
Facility
|
IP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE BAND MODEL 638B 38MM
|
Facility
|
OP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem Medicaid |
$4,156.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Humana KY Medicaid |
$4,156.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE VALVE BAND 26MM
|
Facility
|
OP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem Medicaid |
$4,156.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Humana KY Medicaid |
$4,156.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE VALVE BAND 26MM
|
Facility
|
IP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE VALVE BAND MODEL28MM
|
Facility
|
OP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem Medicaid |
$4,156.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Humana KY Medicaid |
$4,156.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,199.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,240.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
CG FUTURE VALVE BAND MODEL28MM
|
Facility
|
IP
|
$12,087.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,626.34 |
| Max. Negotiated Rate |
$11,604.29 |
| Rate for Payer: Aetna Commercial |
$9,307.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,428.48
|
| Rate for Payer: Cash Price |
$6,043.90
|
| Rate for Payer: Cigna Commercial |
$10,032.87
|
| Rate for Payer: First Health Commercial |
$11,483.41
|
| Rate for Payer: Humana Commercial |
$10,274.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,912.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,920.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,626.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,637.26
|
| Rate for Payer: Ohio Health Group HMO |
$9,065.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,670.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,516.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,340.58
|
| Rate for Payer: PHCS Commercial |
$11,604.29
|
| Rate for Payer: United Healthcare All Payer |
$10,637.26
|
|
|
[C]GUAIF/COD 5ML PO
|
Facility
|
OP
|
$60.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.10 |
| 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 |
$48.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.63
|
| Rate for Payer: PHCS Commercial |
$57.93
|
| Rate for Payer: United Healthcare All Payer |
$53.10
|
|
|
[C]GUAIF/COD 5ML PO
|
Facility
|
IP
|
$60.34
|
|
|
Service Code
|
HCPCS J8499
|
| Hospital Charge Code |
25004516
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$57.93 |
| Rate for Payer: Aetna Commercial |
$46.46
|
| 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: 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: Ohio Health Choice Commercial |
$53.10
|
| Rate for Payer: Ohio Health Group HMO |
$45.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.63
|
| Rate for Payer: PHCS Commercial |
$57.93
|
| Rate for Payer: United Healthcare All Payer |
$53.10
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
OP
|
$849.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
45000282
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$815.04 |
| Rate for Payer: Aetna Commercial |
$653.73
|
| Rate for Payer: Anthem Medicaid |
$291.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$662.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$704.67
|
| Rate for Payer: First Health Commercial |
$806.55
|
| Rate for Payer: Humana Commercial |
$721.65
|
| Rate for Payer: Humana KY Medicaid |
$291.97
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$294.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$696.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$626.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$297.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$747.12
|
| Rate for Payer: Ohio Health Group HMO |
$636.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$679.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.81
|
| Rate for Payer: PHCS Commercial |
$815.04
|
| Rate for Payer: United Healthcare All Payer |
$747.12
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
IP
|
$1,049.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
76102068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$314.70 |
| Max. Negotiated Rate |
$1,007.04 |
| Rate for Payer: Aetna Commercial |
$807.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$818.22
|
| Rate for Payer: Cash Price |
$524.50
|
| Rate for Payer: Cigna Commercial |
$870.67
|
| Rate for Payer: First Health Commercial |
$996.55
|
| Rate for Payer: Humana Commercial |
$891.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$860.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$774.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$314.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$923.12
|
| Rate for Payer: Ohio Health Group HMO |
$786.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$839.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$912.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$723.81
|
| Rate for Payer: PHCS Commercial |
$1,007.04
|
| Rate for Payer: United Healthcare All Payer |
$923.12
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
IP
|
$849.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
45000282
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$254.70 |
| Max. Negotiated Rate |
$815.04 |
| Rate for Payer: Aetna Commercial |
$653.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$662.22
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$704.67
|
| Rate for Payer: First Health Commercial |
$806.55
|
| Rate for Payer: Humana Commercial |
$721.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$696.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$626.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$747.12
|
| Rate for Payer: Ohio Health Group HMO |
$636.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$679.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.81
|
| Rate for Payer: PHCS Commercial |
$815.04
|
| Rate for Payer: United Healthcare All Payer |
$747.12
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Facility
|
OP
|
$1,049.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
76102068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$1,007.04 |
| Rate for Payer: Aetna Commercial |
$807.73
|
| Rate for Payer: Anthem Medicaid |
$360.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$818.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$524.50
|
| Rate for Payer: Cash Price |
$524.50
|
| Rate for Payer: Cigna Commercial |
$870.67
|
| Rate for Payer: First Health Commercial |
$996.55
|
| Rate for Payer: Humana Commercial |
$891.65
|
| Rate for Payer: Humana KY Medicaid |
$360.75
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$364.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$860.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$774.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$367.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$923.12
|
| Rate for Payer: Ohio Health Group HMO |
$786.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$839.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$912.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$723.81
|
| Rate for Payer: PHCS Commercial |
$1,007.04
|
| Rate for Payer: United Healthcare All Payer |
$923.12
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPLE
|
Professional
|
Both
|
$1,049.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
76102068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.35 |
| Max. Negotiated Rate |
$629.40 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Ambetter Exchange |
$49.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.35
|
| Rate for Payer: Anthem Medicaid |
$40.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$49.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$49.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.20
|
| Rate for Payer: Cash Price |
$524.50
|
| Rate for Payer: Cash Price |
$524.50
|
| Rate for Payer: Cigna Commercial |
$180.74
|
| Rate for Payer: Healthspan PPO |
$140.98
|
| Rate for Payer: Humana Medicaid |
$40.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$49.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.01
|
| Rate for Payer: Molina Healthcare Passport |
$40.21
|
| Rate for Payer: Multiplan PHCS |
$629.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$64.13
|
| Rate for Payer: UHCCP Medicaid |
$39.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$49.33
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPL(P
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
761P2068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.35 |
| Max. Negotiated Rate |
$180.74 |
| Rate for Payer: Aetna Commercial |
$107.80
|
| Rate for Payer: Ambetter Exchange |
$49.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.35
|
| Rate for Payer: Anthem Medicaid |
$40.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$49.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$49.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$59.20
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$180.74
|
| Rate for Payer: Healthspan PPO |
$140.98
|
| Rate for Payer: Humana Medicaid |
$40.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$49.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$41.01
|
| Rate for Payer: Molina Healthcare Passport |
$40.21
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$64.13
|
| Rate for Payer: UHCCP Medicaid |
$39.22
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$40.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$49.33
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPL(T
|
Facility
|
OP
|
$849.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
761T2068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$815.04 |
| Rate for Payer: Aetna Commercial |
$653.73
|
| Rate for Payer: Anthem Medicaid |
$291.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$662.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$704.67
|
| Rate for Payer: First Health Commercial |
$806.55
|
| Rate for Payer: Humana Commercial |
$721.65
|
| Rate for Payer: Humana KY Medicaid |
$291.97
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$294.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$696.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$626.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$297.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$747.12
|
| Rate for Payer: Ohio Health Group HMO |
$636.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$679.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.81
|
| Rate for Payer: PHCS Commercial |
$815.04
|
| Rate for Payer: United Healthcare All Payer |
$747.12
|
|
|
CHANGE CYSTOSTOMY TUBE SIMPL(T
|
Facility
|
IP
|
$849.00
|
|
|
Service Code
|
HCPCS 51705
|
| Hospital Charge Code |
761T2068
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$254.70 |
| Max. Negotiated Rate |
$815.04 |
| Rate for Payer: Aetna Commercial |
$653.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$662.22
|
| Rate for Payer: Cash Price |
$424.50
|
| Rate for Payer: Cigna Commercial |
$704.67
|
| Rate for Payer: First Health Commercial |
$806.55
|
| Rate for Payer: Humana Commercial |
$721.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$696.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$626.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$254.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$747.12
|
| Rate for Payer: Ohio Health Group HMO |
$636.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$679.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$738.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.81
|
| Rate for Payer: PHCS Commercial |
$815.04
|
| Rate for Payer: United Healthcare All Payer |
$747.12
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
IP
|
$2,709.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
76102069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$812.70 |
| Max. Negotiated Rate |
$2,600.64 |
| Rate for Payer: Aetna Commercial |
$2,085.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,113.02
|
| Rate for Payer: Cash Price |
$1,354.50
|
| Rate for Payer: Cigna Commercial |
$2,248.47
|
| Rate for Payer: First Health Commercial |
$2,573.55
|
| Rate for Payer: Humana Commercial |
$2,302.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,221.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,999.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$812.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,383.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,031.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,167.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,356.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,869.21
|
| Rate for Payer: PHCS Commercial |
$2,600.64
|
| Rate for Payer: United Healthcare All Payer |
$2,383.92
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
OP
|
$2,164.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
761T2069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$2,077.44 |
| Rate for Payer: Aetna Commercial |
$1,666.28
|
| Rate for Payer: Anthem Medicaid |
$744.20
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,687.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$1,082.00
|
| Rate for Payer: Cash Price |
$1,082.00
|
| Rate for Payer: Cigna Commercial |
$1,796.12
|
| Rate for Payer: First Health Commercial |
$2,055.80
|
| Rate for Payer: Humana Commercial |
$1,839.40
|
| Rate for Payer: Humana KY Medicaid |
$744.20
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$751.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,774.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,597.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$759.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,904.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,623.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,731.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,882.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,493.16
|
| Rate for Payer: PHCS Commercial |
$2,077.44
|
| Rate for Payer: United Healthcare All Payer |
$1,904.32
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Professional
|
Both
|
$545.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
761P2069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.59 |
| Max. Negotiated Rate |
$327.00 |
| Rate for Payer: Aetna Commercial |
$153.84
|
| Rate for Payer: Ambetter Exchange |
$75.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$62.24
|
| Rate for Payer: Anthem Medicaid |
$59.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$75.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$90.29
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cash Price |
$272.50
|
| Rate for Payer: Cigna Commercial |
$261.29
|
| Rate for Payer: Healthspan PPO |
$199.18
|
| Rate for Payer: Humana Medicaid |
$59.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$128.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$75.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.78
|
| Rate for Payer: Molina Healthcare Passport |
$59.59
|
| Rate for Payer: Multiplan PHCS |
$327.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$97.81
|
| Rate for Payer: UHCCP Medicaid |
$65.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$75.24
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
OP
|
$2,709.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
76102069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$616.73 |
| Max. Negotiated Rate |
$2,600.64 |
| Rate for Payer: Aetna Commercial |
$2,085.93
|
| Rate for Payer: Anthem Medicaid |
$931.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$616.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,113.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$863.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$832.59
|
| Rate for Payer: Cash Price |
$1,354.50
|
| Rate for Payer: Cash Price |
$1,354.50
|
| Rate for Payer: Cigna Commercial |
$2,248.47
|
| Rate for Payer: First Health Commercial |
$2,573.55
|
| Rate for Payer: Humana Commercial |
$2,302.65
|
| Rate for Payer: Humana KY Medicaid |
$931.63
|
| Rate for Payer: Humana Medicare Advantage |
$616.73
|
| Rate for Payer: Kentucky WC Medicaid |
$941.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,221.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,999.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$740.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$950.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,383.92
|
| Rate for Payer: Ohio Health Group HMO |
$2,031.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,167.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,356.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,869.21
|
| Rate for Payer: PHCS Commercial |
$2,600.64
|
| Rate for Payer: United Healthcare All Payer |
$2,383.92
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Professional
|
Both
|
$2,709.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
76102069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$59.59 |
| Max. Negotiated Rate |
$1,625.40 |
| Rate for Payer: Aetna Commercial |
$153.84
|
| Rate for Payer: Ambetter Exchange |
$75.24
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$62.24
|
| Rate for Payer: Anthem Medicaid |
$59.59
|
| Rate for Payer: Buckeye Individual/Medicaid |
$75.24
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$90.29
|
| Rate for Payer: Cash Price |
$1,354.50
|
| Rate for Payer: Cash Price |
$1,354.50
|
| Rate for Payer: Cigna Commercial |
$261.29
|
| Rate for Payer: Healthspan PPO |
$199.18
|
| Rate for Payer: Humana Medicaid |
$59.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$128.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$75.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$75.24
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$60.78
|
| Rate for Payer: Molina Healthcare Passport |
$59.59
|
| Rate for Payer: Multiplan PHCS |
$1,625.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$97.81
|
| Rate for Payer: UHCCP Medicaid |
$65.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$60.19
|
| Rate for Payer: Wellcare Medicare Advantage |
$75.24
|
|
|
CHANGE OF CYSTOSTOMY TUBE COMP
|
Facility
|
IP
|
$2,164.00
|
|
|
Service Code
|
HCPCS 51710
|
| Hospital Charge Code |
761T2069
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$649.20 |
| Max. Negotiated Rate |
$2,077.44 |
| Rate for Payer: Aetna Commercial |
$1,666.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,687.92
|
| Rate for Payer: Cash Price |
$1,082.00
|
| Rate for Payer: Cigna Commercial |
$1,796.12
|
| Rate for Payer: First Health Commercial |
$2,055.80
|
| Rate for Payer: Humana Commercial |
$1,839.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,774.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,597.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$649.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,904.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,623.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,731.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,882.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,493.16
|
| Rate for Payer: PHCS Commercial |
$2,077.44
|
| Rate for Payer: United Healthcare All Payer |
$1,904.32
|
|
|
CHANGE OF CYSTOSTOMY TUBE; SIMPLE
|
Facility
|
OP
|
$314.61
|
|
|
Service Code
|
CPT 51705
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$314.61 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
|
|
CHANGE OF URETER TUBE/STENT
|
Facility
|
OP
|
$3,735.00
|
|
|
Service Code
|
HCPCS 50688
|
| Hospital Charge Code |
76102771
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,284.47 |
| Max. Negotiated Rate |
$3,585.60 |
| Rate for Payer: Aetna Commercial |
$2,875.95
|
| Rate for Payer: Anthem Medicaid |
$1,284.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,913.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cash Price |
$1,867.50
|
| Rate for Payer: Cigna Commercial |
$3,100.05
|
| Rate for Payer: First Health Commercial |
$3,548.25
|
| Rate for Payer: Humana Commercial |
$3,174.75
|
| Rate for Payer: Humana KY Medicaid |
$1,284.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,892.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,297.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,062.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,756.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,271.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,310.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,286.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,801.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,988.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,249.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,577.15
|
| Rate for Payer: PHCS Commercial |
$3,585.60
|
| Rate for Payer: United Healthcare All Payer |
$3,286.80
|
|
