|
[C]MSIR (MORPHINE S 15MG/TAB0
|
Facility
|
OP
|
$60.43
|
|
|
Service Code
|
NDC 54023525
|
| Hospital Charge Code |
25000078
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.13 |
| Max. Negotiated Rate |
$58.01 |
| Rate for Payer: Aetna Commercial |
$46.53
|
| Rate for Payer: Anthem Medicaid |
$20.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.14
|
| Rate for Payer: Cash Price |
$30.22
|
| Rate for Payer: Cigna Commercial |
$50.16
|
| Rate for Payer: First Health Commercial |
$57.41
|
| Rate for Payer: Humana Commercial |
$51.37
|
| Rate for Payer: Humana KY Medicaid |
$20.78
|
| Rate for Payer: Kentucky WC Medicaid |
$20.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.18
|
| Rate for Payer: Ohio Health Group HMO |
$45.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.34
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.70
|
| Rate for Payer: PHCS Commercial |
$58.01
|
| Rate for Payer: United Healthcare All Payer |
$53.18
|
|
|
CMT SPINAL 3-4 REGIONS
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 98941
|
| Hospital Charge Code |
42000039
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$20.63 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$23.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$32.73
|
| Rate for Payer: CareSource Just4Me Medicare |
$31.56
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Humana Medicare Advantage |
$23.38
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
CMT SPINAL 3-4 REGIONS
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 98941
|
| Hospital Charge Code |
42000039
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
CNS DNA AMP PROBE TYPE 12-25
|
Facility
|
OP
|
$914.00
|
|
|
Service Code
|
HCPCS 87483
|
| Hospital Charge Code |
30002073
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$416.78 |
| Max. Negotiated Rate |
$877.44 |
| Rate for Payer: Aetna Commercial |
$703.78
|
| Rate for Payer: Anthem Medicaid |
$416.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$416.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$583.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.78
|
| Rate for Payer: Cash Price |
$457.00
|
| Rate for Payer: Cash Price |
$457.00
|
| Rate for Payer: Cigna Commercial |
$758.62
|
| Rate for Payer: First Health Commercial |
$868.30
|
| Rate for Payer: Humana Commercial |
$776.90
|
| Rate for Payer: Humana KY Medicaid |
$416.78
|
| Rate for Payer: Humana Medicare Advantage |
$416.78
|
| Rate for Payer: Kentucky WC Medicaid |
$420.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$749.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$674.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$500.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$804.32
|
| Rate for Payer: Ohio Health Group HMO |
$685.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$731.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$795.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.66
|
| Rate for Payer: PHCS Commercial |
$877.44
|
| Rate for Payer: United Healthcare All Payer |
$804.32
|
|
|
CNS DNA AMP PROBE TYPE 12-25
|
Facility
|
IP
|
$914.00
|
|
|
Service Code
|
HCPCS 87483
|
| Hospital Charge Code |
30002073
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$274.20 |
| Max. Negotiated Rate |
$877.44 |
| Rate for Payer: Aetna Commercial |
$703.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.94
|
| Rate for Payer: Cash Price |
$457.00
|
| Rate for Payer: Cigna Commercial |
$758.62
|
| Rate for Payer: First Health Commercial |
$868.30
|
| Rate for Payer: Humana Commercial |
$776.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$749.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$674.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$274.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$804.32
|
| Rate for Payer: Ohio Health Group HMO |
$685.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$731.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$795.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$630.66
|
| Rate for Payer: PHCS Commercial |
$877.44
|
| Rate for Payer: United Healthcare All Payer |
$804.32
|
|
|
CNTRL OROPHNGL HEMORHG SIMPLE
|
Professional
|
Both
|
$4,699.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
76101714
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$98.79 |
| Max. Negotiated Rate |
$2,819.54 |
| Rate for Payer: Aetna Commercial |
$246.06
|
| Rate for Payer: Ambetter Exchange |
$152.62
|
| Rate for Payer: Anthem Medicaid |
$98.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$152.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$152.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.14
|
| Rate for Payer: Cash Price |
$2,349.61
|
| Rate for Payer: Cash Price |
$2,349.61
|
| Rate for Payer: Cigna Commercial |
$244.68
|
| Rate for Payer: Healthspan PPO |
$207.51
|
| Rate for Payer: Humana Medicaid |
$98.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$152.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$100.77
|
| Rate for Payer: Molina Healthcare Passport |
$98.79
|
| Rate for Payer: Multiplan PHCS |
$2,819.54
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$198.41
|
| Rate for Payer: UHCCP Medicaid |
$1,644.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$99.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$152.62
|
|
|
CNTRL OROPHNGL HEMORHG SIMPLE
|
Facility
|
IP
|
$4,449.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
45000264
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,334.77 |
| Max. Negotiated Rate |
$4,271.26 |
| Rate for Payer: Aetna Commercial |
$3,425.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,470.40
|
| Rate for Payer: Cash Price |
$2,224.61
|
| Rate for Payer: Cigna Commercial |
$3,692.86
|
| Rate for Payer: First Health Commercial |
$4,226.77
|
| Rate for Payer: Humana Commercial |
$3,781.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,648.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,283.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,334.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,915.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,336.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,559.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,870.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,069.97
|
| Rate for Payer: PHCS Commercial |
$4,271.26
|
| Rate for Payer: United Healthcare All Payer |
$3,915.32
|
|
|
CNTRL OROPHNGL HEMORHG SIMPLE
|
Facility
|
OP
|
$4,449.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
45000264
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$470.54 |
| Max. Negotiated Rate |
$4,271.26 |
| Rate for Payer: Aetna Commercial |
$3,425.91
|
| Rate for Payer: Anthem Medicaid |
$1,530.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,470.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$2,224.61
|
| Rate for Payer: Cash Price |
$2,224.61
|
| Rate for Payer: Cigna Commercial |
$3,692.86
|
| Rate for Payer: First Health Commercial |
$4,226.77
|
| Rate for Payer: Humana Commercial |
$3,781.85
|
| Rate for Payer: Humana KY Medicaid |
$1,530.09
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,545.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,648.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,283.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,560.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,915.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,336.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,559.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,870.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,069.97
|
| Rate for Payer: PHCS Commercial |
$4,271.26
|
| Rate for Payer: United Healthcare All Payer |
$3,915.32
|
|
|
CNTRL OROPHNGL HEMORHG SIMPLE
|
Facility
|
IP
|
$4,699.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
76101714
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,409.77 |
| Max. Negotiated Rate |
$4,511.26 |
| Rate for Payer: Aetna Commercial |
$3,618.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,665.40
|
| Rate for Payer: Cash Price |
$2,349.61
|
| Rate for Payer: Cigna Commercial |
$3,900.36
|
| Rate for Payer: First Health Commercial |
$4,464.27
|
| Rate for Payer: Humana Commercial |
$3,994.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,853.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,409.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,135.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,524.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,759.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,088.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,242.47
|
| Rate for Payer: PHCS Commercial |
$4,511.26
|
| Rate for Payer: United Healthcare All Payer |
$4,135.32
|
|
|
CNTRL OROPHNGL HEMORHG SIMPLE
|
Facility
|
OP
|
$4,699.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
76101714
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$470.54 |
| Max. Negotiated Rate |
$4,511.26 |
| Rate for Payer: Aetna Commercial |
$3,618.41
|
| Rate for Payer: Anthem Medicaid |
$1,616.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,665.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$2,349.61
|
| Rate for Payer: Cash Price |
$2,349.61
|
| Rate for Payer: Cigna Commercial |
$3,900.36
|
| Rate for Payer: First Health Commercial |
$4,464.27
|
| Rate for Payer: Humana Commercial |
$3,994.35
|
| Rate for Payer: Humana KY Medicaid |
$1,616.07
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,853.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,135.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,524.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,759.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,088.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,242.47
|
| Rate for Payer: PHCS Commercial |
$4,511.26
|
| Rate for Payer: United Healthcare All Payer |
$4,135.32
|
|
|
CNTRL OROPHNGL HEMORHG SIMPL(P
|
Professional
|
Both
|
$250.00
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
761P1714
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$246.06 |
| Rate for Payer: Aetna Commercial |
$246.06
|
| Rate for Payer: Ambetter Exchange |
$152.62
|
| Rate for Payer: Anthem Medicaid |
$98.79
|
| Rate for Payer: Buckeye Individual/Medicaid |
$152.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$152.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$183.14
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna Commercial |
$244.68
|
| Rate for Payer: Healthspan PPO |
$207.51
|
| Rate for Payer: Humana Medicaid |
$98.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$218.91
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$152.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$152.62
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$100.77
|
| Rate for Payer: Molina Healthcare Passport |
$98.79
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$198.41
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$99.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$152.62
|
|
|
CNTRL OROPHNGL HEMORHG SIMPL(T
|
Facility
|
OP
|
$4,449.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
761T1714
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$470.54 |
| Max. Negotiated Rate |
$4,271.26 |
| Rate for Payer: Aetna Commercial |
$3,425.91
|
| Rate for Payer: Anthem Medicaid |
$1,530.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$470.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,470.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$658.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$635.23
|
| Rate for Payer: Cash Price |
$2,224.61
|
| Rate for Payer: Cash Price |
$2,224.61
|
| Rate for Payer: Cigna Commercial |
$3,692.86
|
| Rate for Payer: First Health Commercial |
$4,226.77
|
| Rate for Payer: Humana Commercial |
$3,781.85
|
| Rate for Payer: Humana KY Medicaid |
$1,530.09
|
| Rate for Payer: Humana Medicare Advantage |
$470.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,545.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,648.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,283.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,560.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,915.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,336.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,559.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,870.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,069.97
|
| Rate for Payer: PHCS Commercial |
$4,271.26
|
| Rate for Payer: United Healthcare All Payer |
$3,915.32
|
|
|
CNTRL OROPHNGL HEMORHG SIMPL(T
|
Facility
|
IP
|
$4,449.23
|
|
|
Service Code
|
HCPCS 42960
|
| Hospital Charge Code |
761T1714
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,334.77 |
| Max. Negotiated Rate |
$4,271.26 |
| Rate for Payer: Aetna Commercial |
$3,425.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,470.40
|
| Rate for Payer: Cash Price |
$2,224.61
|
| Rate for Payer: Cigna Commercial |
$3,692.86
|
| Rate for Payer: First Health Commercial |
$4,226.77
|
| Rate for Payer: Humana Commercial |
$3,781.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,648.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,283.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,334.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,915.32
|
| Rate for Payer: Ohio Health Group HMO |
$3,336.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,559.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,870.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,069.97
|
| Rate for Payer: PHCS Commercial |
$4,271.26
|
| Rate for Payer: United Healthcare All Payer |
$3,915.32
|
|
|
CO2 TOTAL
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 82374
|
| Hospital Charge Code |
30000263
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.18
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
CO2 TOTAL
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 82374
|
| Hospital Charge Code |
30000263
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$4.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$48.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$4.88
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$4.88
|
| Rate for Payer: Humana Medicare Advantage |
$4.88
|
| Rate for Payer: Kentucky WC Medicaid |
$4.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$52.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$41.40
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
COAPTITE 1ML SYRINGE
|
Facility
|
OP
|
$3,989.38
|
|
|
Service Code
|
HCPCS L8606
|
| Hospital Charge Code |
27000284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,196.81 |
| Max. Negotiated Rate |
$3,829.80 |
| Rate for Payer: Aetna Commercial |
$3,071.82
|
| Rate for Payer: Anthem Medicaid |
$1,371.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,111.72
|
| Rate for Payer: Cash Price |
$1,994.69
|
| Rate for Payer: Cigna Commercial |
$3,311.19
|
| Rate for Payer: First Health Commercial |
$3,789.91
|
| Rate for Payer: Humana Commercial |
$3,390.97
|
| Rate for Payer: Humana KY Medicaid |
$1,371.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,385.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,271.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,944.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,196.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,399.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,510.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,992.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,191.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,470.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,752.67
|
| Rate for Payer: PHCS Commercial |
$3,829.80
|
| Rate for Payer: United Healthcare All Payer |
$3,510.65
|
|
|
COAPTITE 1ML SYRINGE
|
Facility
|
IP
|
$3,989.38
|
|
|
Service Code
|
HCPCS L8606
|
| Hospital Charge Code |
27000284
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,196.81 |
| Max. Negotiated Rate |
$3,829.80 |
| Rate for Payer: Aetna Commercial |
$3,071.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,111.72
|
| Rate for Payer: Cash Price |
$1,994.69
|
| Rate for Payer: Cigna Commercial |
$3,311.19
|
| Rate for Payer: First Health Commercial |
$3,789.91
|
| Rate for Payer: Humana Commercial |
$3,390.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,271.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,944.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,196.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,510.65
|
| Rate for Payer: Ohio Health Group HMO |
$2,992.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,191.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,470.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,752.67
|
| Rate for Payer: PHCS Commercial |
$3,829.80
|
| Rate for Payer: United Healthcare All Payer |
$3,510.65
|
|
|
COBALT HV BONE CEMENT 402432
|
Facility
|
IP
|
$1,714.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.26 |
| Max. Negotiated Rate |
$1,645.63 |
| Rate for Payer: Aetna Commercial |
$1,319.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.08
|
| Rate for Payer: Cash Price |
$857.10
|
| Rate for Payer: Cigna Commercial |
$1,422.79
|
| Rate for Payer: First Health Commercial |
$1,628.49
|
| Rate for Payer: Humana Commercial |
$1,457.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,405.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,508.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,285.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,371.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,491.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.80
|
| Rate for Payer: PHCS Commercial |
$1,645.63
|
| Rate for Payer: United Healthcare All Payer |
$1,508.50
|
|
|
COBALT HV BONE CEMENT 402432
|
Facility
|
OP
|
$1,714.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$514.26 |
| Max. Negotiated Rate |
$1,645.63 |
| Rate for Payer: Aetna Commercial |
$1,319.93
|
| Rate for Payer: Anthem Medicaid |
$589.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,337.08
|
| Rate for Payer: Cash Price |
$857.10
|
| Rate for Payer: Cigna Commercial |
$1,422.79
|
| Rate for Payer: First Health Commercial |
$1,628.49
|
| Rate for Payer: Humana Commercial |
$1,457.07
|
| Rate for Payer: Humana KY Medicaid |
$589.51
|
| Rate for Payer: Kentucky WC Medicaid |
$595.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,405.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,265.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$514.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$601.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,508.50
|
| Rate for Payer: Ohio Health Group HMO |
$1,285.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,371.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,491.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,182.80
|
| Rate for Payer: PHCS Commercial |
$1,645.63
|
| Rate for Payer: United Healthcare All Payer |
$1,508.50
|
|
|
COBALT XT HF CRT
|
Facility
|
OP
|
$75,543.12
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,662.94 |
| Max. Negotiated Rate |
$72,521.40 |
| Rate for Payer: Aetna Commercial |
$58,168.20
|
| Rate for Payer: Anthem Medicaid |
$25,979.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,923.63
|
| Rate for Payer: Cash Price |
$37,771.56
|
| Rate for Payer: Cigna Commercial |
$62,700.79
|
| Rate for Payer: First Health Commercial |
$71,765.96
|
| Rate for Payer: Humana Commercial |
$64,211.65
|
| Rate for Payer: Humana KY Medicaid |
$25,979.28
|
| Rate for Payer: Kentucky WC Medicaid |
$26,243.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,945.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,750.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,662.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,500.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,477.95
|
| Rate for Payer: Ohio Health Group HMO |
$56,657.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,434.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,722.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,124.75
|
| Rate for Payer: PHCS Commercial |
$72,521.40
|
| Rate for Payer: United Healthcare All Payer |
$66,477.95
|
|
|
COBALT XT HF CRT
|
Facility
|
IP
|
$75,543.12
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,662.94 |
| Max. Negotiated Rate |
$72,521.40 |
| Rate for Payer: Aetna Commercial |
$58,168.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,923.63
|
| Rate for Payer: Cash Price |
$37,771.56
|
| Rate for Payer: Cigna Commercial |
$62,700.79
|
| Rate for Payer: First Health Commercial |
$71,765.96
|
| Rate for Payer: Humana Commercial |
$64,211.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,945.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,750.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,662.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,477.95
|
| Rate for Payer: Ohio Health Group HMO |
$56,657.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,434.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,722.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,124.75
|
| Rate for Payer: PHCS Commercial |
$72,521.40
|
| Rate for Payer: United Healthcare All Payer |
$66,477.95
|
|
|
COBALT XT HF CRT SURE SCAN
|
Facility
|
IP
|
$75,543.12
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,662.94 |
| Max. Negotiated Rate |
$72,521.40 |
| Rate for Payer: Aetna Commercial |
$58,168.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,923.63
|
| Rate for Payer: Cash Price |
$37,771.56
|
| Rate for Payer: Cigna Commercial |
$62,700.79
|
| Rate for Payer: First Health Commercial |
$71,765.96
|
| Rate for Payer: Humana Commercial |
$64,211.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,945.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,750.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,662.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,477.95
|
| Rate for Payer: Ohio Health Group HMO |
$56,657.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,434.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,722.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,124.75
|
| Rate for Payer: PHCS Commercial |
$72,521.40
|
| Rate for Payer: United Healthcare All Payer |
$66,477.95
|
|
|
COBALT XT HF CRT SURE SCAN
|
Facility
|
OP
|
$75,543.12
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,662.94 |
| Max. Negotiated Rate |
$72,521.40 |
| Rate for Payer: Aetna Commercial |
$58,168.20
|
| Rate for Payer: Anthem Medicaid |
$25,979.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,923.63
|
| Rate for Payer: Cash Price |
$37,771.56
|
| Rate for Payer: Cigna Commercial |
$62,700.79
|
| Rate for Payer: First Health Commercial |
$71,765.96
|
| Rate for Payer: Humana Commercial |
$64,211.65
|
| Rate for Payer: Humana KY Medicaid |
$25,979.28
|
| Rate for Payer: Kentucky WC Medicaid |
$26,243.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,945.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,750.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,662.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,500.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,477.95
|
| Rate for Payer: Ohio Health Group HMO |
$56,657.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,434.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,722.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,124.75
|
| Rate for Payer: PHCS Commercial |
$72,521.40
|
| Rate for Payer: United Healthcare All Payer |
$66,477.95
|
|
|
COBALT XT HF QUAD CRT-D
|
Facility
|
IP
|
$75,543.12
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,662.94 |
| Max. Negotiated Rate |
$72,521.40 |
| Rate for Payer: Aetna Commercial |
$58,168.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,923.63
|
| Rate for Payer: Cash Price |
$37,771.56
|
| Rate for Payer: Cigna Commercial |
$62,700.79
|
| Rate for Payer: First Health Commercial |
$71,765.96
|
| Rate for Payer: Humana Commercial |
$64,211.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,945.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,750.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,662.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,477.95
|
| Rate for Payer: Ohio Health Group HMO |
$56,657.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,434.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,722.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,124.75
|
| Rate for Payer: PHCS Commercial |
$72,521.40
|
| Rate for Payer: United Healthcare All Payer |
$66,477.95
|
|
|
COBALT XT HF QUAD CRT-D
|
Facility
|
OP
|
$75,543.12
|
|
|
Service Code
|
HCPCS C1882
|
| Hospital Charge Code |
27000045
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$22,662.94 |
| Max. Negotiated Rate |
$72,521.40 |
| Rate for Payer: Aetna Commercial |
$58,168.20
|
| Rate for Payer: Anthem Medicaid |
$25,979.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,923.63
|
| Rate for Payer: Cash Price |
$37,771.56
|
| Rate for Payer: Cigna Commercial |
$62,700.79
|
| Rate for Payer: First Health Commercial |
$71,765.96
|
| Rate for Payer: Humana Commercial |
$64,211.65
|
| Rate for Payer: Humana KY Medicaid |
$25,979.28
|
| Rate for Payer: Kentucky WC Medicaid |
$26,243.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,945.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,750.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,662.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,500.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,477.95
|
| Rate for Payer: Ohio Health Group HMO |
$56,657.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60,434.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$65,722.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52,124.75
|
| Rate for Payer: PHCS Commercial |
$72,521.40
|
| Rate for Payer: United Healthcare All Payer |
$66,477.95
|
|
