|
CLOSURE OF MEDIAN STERNOTOMY
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 21750
|
| Hospital Charge Code |
76100406
|
|
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
|
|
|
CLOSURE OF MEDIAN STERNOTOMY
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 21750
|
| Hospital Charge Code |
76100406
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$526.84 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,078.46
|
| Rate for Payer: Ambetter Exchange |
$641.59
|
| Rate for Payer: Anthem Medicaid |
$526.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$641.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$641.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$769.91
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,156.14
|
| Rate for Payer: Healthspan PPO |
$976.85
|
| Rate for Payer: Humana Medicaid |
$526.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$902.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$641.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$537.38
|
| Rate for Payer: Molina Healthcare Passport |
$526.84
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$834.07
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$532.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$641.59
|
|
|
CLOSURE OF MEDIAN STERNOTOMY(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 21750
|
| Hospital Charge Code |
761P0406
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$526.84 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,078.46
|
| Rate for Payer: Ambetter Exchange |
$641.59
|
| Rate for Payer: Anthem Medicaid |
$526.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$641.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$641.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$769.91
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,156.14
|
| Rate for Payer: Healthspan PPO |
$976.85
|
| Rate for Payer: Humana Medicaid |
$526.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$902.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$641.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$641.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$537.38
|
| Rate for Payer: Molina Healthcare Passport |
$526.84
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$834.07
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$532.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$641.59
|
|
|
CLOSURE OF SPLIT WOUND
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 12021
|
| Hospital Charge Code |
76102750
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$71.81 |
| Max. Negotiated Rate |
$213.10 |
| Rate for Payer: Aetna Commercial |
$196.71
|
| Rate for Payer: Ambetter Exchange |
$131.86
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$71.81
|
| Rate for Payer: Anthem Medicaid |
$71.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$131.86
|
| Rate for Payer: Buckeye Medicare Advantage |
$131.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$158.23
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$213.10
|
| Rate for Payer: Healthspan PPO |
$178.27
|
| Rate for Payer: Humana Medicaid |
$71.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$169.63
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$131.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$131.86
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$73.27
|
| Rate for Payer: Molina Healthcare Passport |
$71.83
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$171.42
|
| Rate for Payer: UHCCP Medicaid |
$75.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$72.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$131.86
|
|
|
CLOSURE OF SPLIT WOUND
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
76100133
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$342.00 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna Commercial |
$877.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.20
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$946.20
|
| Rate for Payer: First Health Commercial |
$1,083.00
|
| Rate for Payer: Humana Commercial |
$969.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$934.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$841.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$342.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,003.20
|
| Rate for Payer: Ohio Health Group HMO |
$855.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.60
|
| Rate for Payer: PHCS Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare All Payer |
$1,003.20
|
|
|
CLOSURE OF SPLIT WOUND
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
76100133
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$392.05 |
| Max. Negotiated Rate |
$1,094.40 |
| Rate for Payer: Aetna Commercial |
$877.80
|
| Rate for Payer: Anthem Medicaid |
$392.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$889.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$946.20
|
| Rate for Payer: First Health Commercial |
$1,083.00
|
| Rate for Payer: Humana Commercial |
$969.00
|
| Rate for Payer: Humana KY Medicaid |
$392.05
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$396.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$934.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$841.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$399.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,003.20
|
| Rate for Payer: Ohio Health Group HMO |
$855.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$912.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$991.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$786.60
|
| Rate for Payer: PHCS Commercial |
$1,094.40
|
| Rate for Payer: United Healthcare All Payer |
$1,003.20
|
|
|
CLOSURE OF SPLIT WOUND
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
45000054
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$271.68 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem Medicaid |
$271.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Humana KY Medicaid |
$271.68
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$274.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$277.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.10
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
CLOSURE OF SPLIT WOUND
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
45000054
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$237.00 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.10
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
CLOSURE OF SPLIT WOUND
|
Professional
|
Both
|
$1,140.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
76100133
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.52 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna Commercial |
$270.11
|
| Rate for Payer: Ambetter Exchange |
$177.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.52
|
| Rate for Payer: Anthem Medicaid |
$111.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$177.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$177.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$213.53
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna Commercial |
$366.47
|
| Rate for Payer: Healthspan PPO |
$296.42
|
| Rate for Payer: Humana Medicaid |
$111.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$230.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$177.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$113.93
|
| Rate for Payer: Molina Healthcare Passport |
$111.70
|
| Rate for Payer: Multiplan PHCS |
$684.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.32
|
| Rate for Payer: UHCCP Medicaid |
$100.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$112.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$177.94
|
|
|
CLOSURE OF SPLIT WOUND(P
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
761P0133
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$95.52 |
| Max. Negotiated Rate |
$366.47 |
| Rate for Payer: Aetna Commercial |
$270.11
|
| Rate for Payer: Ambetter Exchange |
$177.94
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$95.52
|
| Rate for Payer: Anthem Medicaid |
$111.70
|
| Rate for Payer: Buckeye Individual/Medicaid |
$177.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$177.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$213.53
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cash Price |
$175.00
|
| Rate for Payer: Cigna Commercial |
$366.47
|
| Rate for Payer: Healthspan PPO |
$296.42
|
| Rate for Payer: Humana Medicaid |
$111.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$230.04
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$177.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$177.94
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$113.93
|
| Rate for Payer: Molina Healthcare Passport |
$111.70
|
| Rate for Payer: Multiplan PHCS |
$210.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.32
|
| Rate for Payer: UHCCP Medicaid |
$100.30
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$112.82
|
| Rate for Payer: Wellcare Medicare Advantage |
$177.94
|
|
|
CLOSURE OF SPLIT WOUND(T
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
761T0133
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$271.68 |
| Max. Negotiated Rate |
$791.84 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem Medicaid |
$271.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$565.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$791.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$763.56
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Humana KY Medicaid |
$271.68
|
| Rate for Payer: Humana Medicare Advantage |
$565.60
|
| Rate for Payer: Kentucky WC Medicaid |
$274.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$678.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$277.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.10
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
CLOSURE OF SPLIT WOUND(T
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
HCPCS 12020
|
| Hospital Charge Code |
761T0133
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$237.00 |
| Max. Negotiated Rate |
$758.40 |
| Rate for Payer: Aetna Commercial |
$608.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$616.20
|
| Rate for Payer: Cash Price |
$395.00
|
| Rate for Payer: Cigna Commercial |
$655.70
|
| Rate for Payer: First Health Commercial |
$750.50
|
| Rate for Payer: Humana Commercial |
$671.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$647.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$583.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$695.20
|
| Rate for Payer: Ohio Health Group HMO |
$592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$632.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$687.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$545.10
|
| Rate for Payer: PHCS Commercial |
$758.40
|
| Rate for Payer: United Healthcare All Payer |
$695.20
|
|
|
CLOT TRIEVER BOLD CATH.
|
Facility
|
IP
|
$31,250.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9,375.00 |
| Max. Negotiated Rate |
$30,000.00 |
| Rate for Payer: Aetna Commercial |
$24,062.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,375.00
|
| Rate for Payer: Cash Price |
$15,625.00
|
| Rate for Payer: Cigna Commercial |
$25,937.50
|
| Rate for Payer: First Health Commercial |
$29,687.50
|
| Rate for Payer: Humana Commercial |
$26,562.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,625.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,062.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,375.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,500.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27,187.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,562.50
|
| Rate for Payer: PHCS Commercial |
$30,000.00
|
| Rate for Payer: United Healthcare All Payer |
$27,500.00
|
|
|
CLOT TRIEVER BOLD CATH.
|
Facility
|
OP
|
$31,250.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9,375.00 |
| Max. Negotiated Rate |
$30,000.00 |
| Rate for Payer: Aetna Commercial |
$24,062.50
|
| Rate for Payer: Anthem Medicaid |
$10,746.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,375.00
|
| Rate for Payer: Cash Price |
$15,625.00
|
| Rate for Payer: Cigna Commercial |
$25,937.50
|
| Rate for Payer: First Health Commercial |
$29,687.50
|
| Rate for Payer: Humana Commercial |
$26,562.50
|
| Rate for Payer: Humana KY Medicaid |
$10,746.88
|
| Rate for Payer: Kentucky WC Medicaid |
$10,856.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,625.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,062.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,375.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,962.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,500.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27,187.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,562.50
|
| Rate for Payer: PHCS Commercial |
$30,000.00
|
| Rate for Payer: United Healthcare All Payer |
$27,500.00
|
|
|
CLOT TRIEVER CATHETER
|
Facility
|
OP
|
$31,250.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9,375.00 |
| Max. Negotiated Rate |
$30,000.00 |
| Rate for Payer: Aetna Commercial |
$24,062.50
|
| Rate for Payer: Anthem Medicaid |
$10,746.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,375.00
|
| Rate for Payer: Cash Price |
$15,625.00
|
| Rate for Payer: Cigna Commercial |
$25,937.50
|
| Rate for Payer: First Health Commercial |
$29,687.50
|
| Rate for Payer: Humana Commercial |
$26,562.50
|
| Rate for Payer: Humana KY Medicaid |
$10,746.88
|
| Rate for Payer: Kentucky WC Medicaid |
$10,856.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,625.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,062.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,375.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,962.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,500.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27,187.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,562.50
|
| Rate for Payer: PHCS Commercial |
$30,000.00
|
| Rate for Payer: United Healthcare All Payer |
$27,500.00
|
|
|
CLOT TRIEVER CATHETER
|
Facility
|
IP
|
$31,250.00
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9,375.00 |
| Max. Negotiated Rate |
$30,000.00 |
| Rate for Payer: Aetna Commercial |
$24,062.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24,375.00
|
| Rate for Payer: Cash Price |
$15,625.00
|
| Rate for Payer: Cigna Commercial |
$25,937.50
|
| Rate for Payer: First Health Commercial |
$29,687.50
|
| Rate for Payer: Humana Commercial |
$26,562.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25,625.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$23,062.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,375.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$27,500.00
|
| Rate for Payer: Ohio Health Group HMO |
$23,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$27,187.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,562.50
|
| Rate for Payer: PHCS Commercial |
$30,000.00
|
| Rate for Payer: United Healthcare All Payer |
$27,500.00
|
|
|
CLOT TRIEVER SHEATH
|
Facility
|
OP
|
$10,840.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,252.00 |
| Max. Negotiated Rate |
$10,406.40 |
| Rate for Payer: Aetna Commercial |
$8,346.80
|
| Rate for Payer: Anthem Medicaid |
$3,727.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,455.20
|
| Rate for Payer: Cash Price |
$5,420.00
|
| Rate for Payer: Cigna Commercial |
$8,997.20
|
| Rate for Payer: First Health Commercial |
$10,298.00
|
| Rate for Payer: Humana Commercial |
$9,214.00
|
| Rate for Payer: Humana KY Medicaid |
$3,727.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,765.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,888.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,999.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,252.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,802.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,539.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,130.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,430.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,479.60
|
| Rate for Payer: PHCS Commercial |
$10,406.40
|
| Rate for Payer: United Healthcare All Payer |
$9,539.20
|
|
|
CLOT TRIEVER SHEATH
|
Facility
|
IP
|
$10,840.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,252.00 |
| Max. Negotiated Rate |
$10,406.40 |
| Rate for Payer: Aetna Commercial |
$8,346.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,455.20
|
| Rate for Payer: Cash Price |
$5,420.00
|
| Rate for Payer: Cigna Commercial |
$8,997.20
|
| Rate for Payer: First Health Commercial |
$10,298.00
|
| Rate for Payer: Humana Commercial |
$9,214.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,888.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,999.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,252.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,539.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,130.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,672.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,430.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,479.60
|
| Rate for Payer: PHCS Commercial |
$10,406.40
|
| Rate for Payer: United Healthcare All Payer |
$9,539.20
|
|
|
CLOZAPINE
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
NDC 60687041501
|
| Hospital Charge Code |
25000437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
CLOZAPINE
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 60687041501
|
| Hospital Charge Code |
25000437
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.67
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
CLOZARIL 25MG TABLET
|
Facility
|
IP
|
$4.86
|
|
|
Service Code
|
NDC 60687040401
|
| Hospital Charge Code |
25000438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
CLOZARIL 25MG TABLET
|
Facility
|
OP
|
$4.86
|
|
|
Service Code
|
NDC 60687040401
|
| Hospital Charge Code |
25000438
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$4.67 |
| Rate for Payer: Aetna Commercial |
$3.74
|
| Rate for Payer: Anthem Medicaid |
$1.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.79
|
| Rate for Payer: Cash Price |
$2.43
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.62
|
| Rate for Payer: Humana Commercial |
$4.13
|
| Rate for Payer: Humana KY Medicaid |
$1.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.28
|
| Rate for Payer: Ohio Health Group HMO |
$3.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.35
|
| Rate for Payer: PHCS Commercial |
$4.67
|
| Rate for Payer: United Healthcare All Payer |
$4.28
|
|
|
CL PHLNGL FX PRX/MID PXFT WMAN
|
Facility
|
OP
|
$1,562.00
|
|
|
Service Code
|
HCPCS 26725
|
| Hospital Charge Code |
76100737
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$1,499.52 |
| Rate for Payer: Aetna Commercial |
$1,202.74
|
| Rate for Payer: Anthem Medicaid |
$537.17
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,218.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cash Price |
$781.00
|
| Rate for Payer: Cigna Commercial |
$1,296.46
|
| Rate for Payer: First Health Commercial |
$1,483.90
|
| Rate for Payer: Humana Commercial |
$1,327.70
|
| Rate for Payer: Humana KY Medicaid |
$537.17
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$542.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,280.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,152.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$547.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,374.56
|
| Rate for Payer: Ohio Health Group HMO |
$1,171.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,249.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,358.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,077.78
|
| Rate for Payer: PHCS Commercial |
$1,499.52
|
| Rate for Payer: United Healthcare All Payer |
$1,374.56
|
|
|
CL PHLNGL FX PRX/MID PXFT WMAN
|
Facility
|
OP
|
$932.00
|
|
|
Service Code
|
HCPCS 26725
|
| Hospital Charge Code |
45000144
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$894.72 |
| Rate for Payer: Aetna Commercial |
$717.64
|
| Rate for Payer: Anthem Medicaid |
$320.51
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$221.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$726.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$310.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$299.21
|
| Rate for Payer: Cash Price |
$466.00
|
| Rate for Payer: Cash Price |
$466.00
|
| Rate for Payer: Cigna Commercial |
$773.56
|
| Rate for Payer: First Health Commercial |
$885.40
|
| Rate for Payer: Humana Commercial |
$792.20
|
| Rate for Payer: Humana KY Medicaid |
$320.51
|
| Rate for Payer: Humana Medicare Advantage |
$221.64
|
| Rate for Payer: Kentucky WC Medicaid |
$323.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$764.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$687.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$265.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$326.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$820.16
|
| Rate for Payer: Ohio Health Group HMO |
$699.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$745.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$810.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$643.08
|
| Rate for Payer: PHCS Commercial |
$894.72
|
| Rate for Payer: United Healthcare All Payer |
$820.16
|
|
|
CL PHLNGL FX PRX/MID PXFT WMAN
|
Professional
|
Both
|
$630.00
|
|
|
Service Code
|
HCPCS 26725
|
| Hospital Charge Code |
761P0737
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$140.21 |
| Max. Negotiated Rate |
$524.26 |
| Rate for Payer: Aetna Commercial |
$417.54
|
| Rate for Payer: Ambetter Exchange |
$296.44
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$158.50
|
| Rate for Payer: Anthem Medicaid |
$140.21
|
| Rate for Payer: Buckeye Individual/Medicaid |
$296.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$296.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$355.73
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cash Price |
$315.00
|
| Rate for Payer: Cigna Commercial |
$524.26
|
| Rate for Payer: Healthspan PPO |
$417.47
|
| Rate for Payer: Humana Medicaid |
$140.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$364.28
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$296.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$296.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$143.01
|
| Rate for Payer: Molina Healthcare Passport |
$140.21
|
| Rate for Payer: Multiplan PHCS |
$378.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$385.37
|
| Rate for Payer: UHCCP Medicaid |
$166.43
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$141.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$296.44
|
|
