|
COSM MAMMO W/O LIP 120 M
|
Professional
|
Both
|
$1,750.00
|
|
| Hospital Charge Code |
22200082
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$612.50 |
| Max. Negotiated Rate |
$1,750.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$1,750.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Multiplan PHCS |
$1,050.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,225.00
|
| Rate for Payer: UHCCP Medicaid |
$612.50
|
|
|
COSM MAMMO W/O LIPO 120M -80
|
Professional
|
Both
|
$875.00
|
|
| Hospital Charge Code |
22200383
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$306.25 |
| Max. Negotiated Rate |
$875.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$875.00
|
| Rate for Payer: Cash Price |
$437.50
|
| Rate for Payer: Multiplan PHCS |
$525.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$612.50
|
| Rate for Payer: UHCCP Medicaid |
$306.25
|
|
|
COSM SCLEROTHERAPY MULT VEINS
|
Professional
|
Both
|
$950.00
|
|
| Hospital Charge Code |
22200196
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$332.50 |
| Max. Negotiated Rate |
$950.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$950.00
|
| Rate for Payer: Cash Price |
$475.00
|
| Rate for Payer: Multiplan PHCS |
$570.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$665.00
|
| Rate for Payer: UHCCP Medicaid |
$332.50
|
|
|
COSM SCLEROTHERAPY SINGLE VEIN
|
Professional
|
Both
|
$475.00
|
|
| Hospital Charge Code |
22200195
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$166.25 |
| Max. Negotiated Rate |
$475.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$475.00
|
| Rate for Payer: Cash Price |
$237.50
|
| Rate for Payer: Multiplan PHCS |
$285.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$332.50
|
| Rate for Payer: UHCCP Medicaid |
$166.25
|
|
|
COSM SCLEROTHERAPY SPOT VEIN
|
Professional
|
Both
|
$275.00
|
|
| Hospital Charge Code |
22200194
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$96.25 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$96.25
|
|
|
COSOPT PLUS 10 ML
|
Facility
|
OP
|
$27.10
|
|
|
Service Code
|
NDC 61314003002
|
| Hospital Charge Code |
25000483
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$26.02 |
| Rate for Payer: Humana Commercial |
$23.04
|
| Rate for Payer: Humana KY Medicaid |
$9.32
|
| Rate for Payer: Kentucky WC Medicaid |
$9.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.85
|
| Rate for Payer: Ohio Health Group HMO |
$20.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.40
|
| Rate for Payer: PHCS Commercial |
$26.02
|
| Rate for Payer: United Healthcare All Payer |
$23.85
|
| Rate for Payer: Aetna Commercial |
$20.87
|
| Rate for Payer: Anthem Medicaid |
$9.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.14
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna Commercial |
$22.49
|
| Rate for Payer: First Health Commercial |
$25.74
|
|
|
COSOPT PLUS 10 ML
|
Facility
|
IP
|
$27.10
|
|
|
Service Code
|
NDC 61314003002
|
| Hospital Charge Code |
25000483
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$26.02 |
| Rate for Payer: Aetna Commercial |
$20.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.14
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cigna Commercial |
$22.49
|
| Rate for Payer: First Health Commercial |
$25.74
|
| Rate for Payer: Humana Commercial |
$23.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$23.85
|
| Rate for Payer: Ohio Health Group HMO |
$20.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.40
|
| Rate for Payer: PHCS Commercial |
$26.02
|
| Rate for Payer: United Healthcare All Payer |
$23.85
|
|
|
COSYNTROPIN 0.25MG SDV
|
Professional
|
Both
|
$518.58
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
63600216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.71 |
| Max. Negotiated Rate |
$518.58 |
| Rate for Payer: Aetna Commercial |
$48.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$518.58
|
| Rate for Payer: Cash Price |
$259.29
|
| Rate for Payer: Cash Price |
$259.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$48.71
|
| Rate for Payer: Multiplan PHCS |
$311.15
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$363.01
|
| Rate for Payer: UHCCP Medicaid |
$181.50
|
|
|
COSYNTROPIN 0.25MG SDV
|
Facility
|
OP
|
$518.58
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
636T0216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.42 |
| Max. Negotiated Rate |
$497.84 |
| Rate for Payer: Aetna Commercial |
$399.31
|
| Rate for Payer: Anthem Medicaid |
$178.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.49
|
| Rate for Payer: Cash Price |
$259.29
|
| Rate for Payer: Cigna Commercial |
$430.42
|
| Rate for Payer: First Health Commercial |
$492.65
|
| Rate for Payer: Humana Commercial |
$440.79
|
| Rate for Payer: Humana KY Medicaid |
$178.34
|
| Rate for Payer: Kentucky WC Medicaid |
$180.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$382.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$181.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.35
|
| Rate for Payer: Ohio Health Group HMO |
$388.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.76
|
| Rate for Payer: PHCS Commercial |
$497.84
|
| Rate for Payer: United Healthcare All Payer |
$456.35
|
|
|
COSYNTROPIN 0.25MG SDV
|
Facility
|
IP
|
$518.58
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
636T0216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.42 |
| Max. Negotiated Rate |
$497.84 |
| Rate for Payer: Aetna Commercial |
$399.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.49
|
| Rate for Payer: Cash Price |
$259.29
|
| Rate for Payer: Cigna Commercial |
$430.42
|
| Rate for Payer: First Health Commercial |
$492.65
|
| Rate for Payer: Humana Commercial |
$440.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$382.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.35
|
| Rate for Payer: Ohio Health Group HMO |
$388.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.76
|
| Rate for Payer: PHCS Commercial |
$497.84
|
| Rate for Payer: United Healthcare All Payer |
$456.35
|
|
|
COSYNTROPIN 0.25MG SDV
|
Facility
|
IP
|
$518.58
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
63600216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.42 |
| Max. Negotiated Rate |
$497.84 |
| Rate for Payer: Aetna Commercial |
$399.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.49
|
| Rate for Payer: Cash Price |
$259.29
|
| Rate for Payer: Cigna Commercial |
$430.42
|
| Rate for Payer: First Health Commercial |
$492.65
|
| Rate for Payer: Humana Commercial |
$440.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$382.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.35
|
| Rate for Payer: Ohio Health Group HMO |
$388.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.76
|
| Rate for Payer: PHCS Commercial |
$497.84
|
| Rate for Payer: United Healthcare All Payer |
$456.35
|
|
|
COSYNTROPIN 0.25MG SDV
|
Facility
|
OP
|
$518.58
|
|
|
Service Code
|
HCPCS J0834
|
| Hospital Charge Code |
63600216
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$67.42 |
| Max. Negotiated Rate |
$497.84 |
| Rate for Payer: Aetna Commercial |
$399.31
|
| Rate for Payer: Anthem Medicaid |
$178.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$404.49
|
| Rate for Payer: Cash Price |
$259.29
|
| Rate for Payer: Cigna Commercial |
$430.42
|
| Rate for Payer: First Health Commercial |
$492.65
|
| Rate for Payer: Humana Commercial |
$440.79
|
| Rate for Payer: Humana KY Medicaid |
$178.34
|
| Rate for Payer: Kentucky WC Medicaid |
$180.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$425.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$382.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$155.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$181.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$456.35
|
| Rate for Payer: Ohio Health Group HMO |
$388.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$103.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$67.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$160.76
|
| Rate for Payer: PHCS Commercial |
$497.84
|
| Rate for Payer: United Healthcare All Payer |
$456.35
|
|
|
COUNSEL NEED LUNG CA SCREEN
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
51000138
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.06 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$21.06
|
| Rate for Payer: Anthem Medicaid |
$42.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Humana Medicaid |
$42.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$35.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$43.71
|
| Rate for Payer: Molina Healthcare Passport |
$42.85
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$22.11
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$43.28
|
|
|
COUNSEL NEED LUNG CA SCREEN
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
51000138
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$96.00 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$30.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
COUNSEL NEED LUNG CA SCREEN
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS G0296
|
| Hospital Charge Code |
51000138
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$107.91 |
| Rate for Payer: Aetna Commercial |
$77.00
|
| Rate for Payer: Anthem Medicaid |
$34.39
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$77.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$78.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$107.91
|
| Rate for Payer: CareSource Just4Me Medicare |
$104.06
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$83.00
|
| Rate for Payer: First Health Commercial |
$95.00
|
| Rate for Payer: Humana Commercial |
$85.00
|
| Rate for Payer: Humana KY Medicaid |
$34.39
|
| Rate for Payer: Humana Medicare Advantage |
$77.08
|
| Rate for Payer: Kentucky WC Medicaid |
$34.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$73.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$92.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$35.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$88.00
|
| Rate for Payer: Ohio Health Group HMO |
$75.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$31.00
|
| Rate for Payer: PHCS Commercial |
$96.00
|
| Rate for Payer: United Healthcare All Payer |
$88.00
|
|
|
COUNTERSINK HEADLESS 4.0
|
Facility
|
OP
|
$1,787.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$1,716.00 |
| Rate for Payer: Aetna Commercial |
$1,376.38
|
| Rate for Payer: Anthem Medicaid |
$614.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,394.25
|
| Rate for Payer: Cash Price |
$893.75
|
| Rate for Payer: Cigna Commercial |
$1,483.62
|
| Rate for Payer: First Health Commercial |
$1,698.12
|
| Rate for Payer: Humana Commercial |
$1,519.38
|
| Rate for Payer: Humana KY Medicaid |
$614.72
|
| Rate for Payer: Kentucky WC Medicaid |
$620.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,465.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,319.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$536.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$627.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,573.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,340.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$554.12
|
| Rate for Payer: PHCS Commercial |
$1,716.00
|
| Rate for Payer: United Healthcare All Payer |
$1,573.00
|
|
|
COUNTERSINK HEADLESS 4.0
|
Facility
|
IP
|
$1,787.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$232.38 |
| Max. Negotiated Rate |
$1,716.00 |
| Rate for Payer: Aetna Commercial |
$1,376.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,394.25
|
| Rate for Payer: Cash Price |
$893.75
|
| Rate for Payer: Cigna Commercial |
$1,483.62
|
| Rate for Payer: First Health Commercial |
$1,698.12
|
| Rate for Payer: Humana Commercial |
$1,519.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,465.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,319.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$536.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,573.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,340.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$357.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$232.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$554.12
|
| Rate for Payer: PHCS Commercial |
$1,716.00
|
| Rate for Payer: United Healthcare All Payer |
$1,573.00
|
|
|
COUPLER MINI MALE TO MALE 2MM
|
Facility
|
IP
|
$8,410.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.42 |
| Max. Negotiated Rate |
$8,074.52 |
| Rate for Payer: Aetna Commercial |
$6,476.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,560.55
|
| Rate for Payer: Cash Price |
$4,205.48
|
| Rate for Payer: Cigna Commercial |
$6,981.10
|
| Rate for Payer: First Health Commercial |
$7,990.41
|
| Rate for Payer: Humana Commercial |
$7,149.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,896.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,207.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,523.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,401.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,308.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,682.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,093.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,607.40
|
| Rate for Payer: PHCS Commercial |
$8,074.52
|
| Rate for Payer: United Healthcare All Payer |
$7,401.64
|
|
|
COUPLER MINI MALE TO MALE 2MM
|
Facility
|
OP
|
$8,410.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.42 |
| Max. Negotiated Rate |
$8,074.52 |
| Rate for Payer: Cigna Commercial |
$6,981.10
|
| Rate for Payer: Aetna Commercial |
$6,476.44
|
| Rate for Payer: Anthem Medicaid |
$2,892.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,560.55
|
| Rate for Payer: Cash Price |
$4,205.48
|
| Rate for Payer: First Health Commercial |
$7,990.41
|
| Rate for Payer: Humana Commercial |
$7,149.32
|
| Rate for Payer: Humana KY Medicaid |
$2,892.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,921.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,896.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,207.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,523.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,950.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,401.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,308.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,682.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,093.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,607.40
|
| Rate for Payer: PHCS Commercial |
$8,074.52
|
| Rate for Payer: United Healthcare All Payer |
$7,401.64
|
|
|
COUPLER MINI MALE TO MALE 4MM
|
Facility
|
IP
|
$8,410.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.42 |
| Max. Negotiated Rate |
$8,074.52 |
| Rate for Payer: Aetna Commercial |
$6,476.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,560.55
|
| Rate for Payer: Cash Price |
$4,205.48
|
| Rate for Payer: Cigna Commercial |
$6,981.10
|
| Rate for Payer: First Health Commercial |
$7,990.41
|
| Rate for Payer: Humana Commercial |
$7,149.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,896.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,207.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,523.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,401.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,308.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,682.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,093.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,607.40
|
| Rate for Payer: PHCS Commercial |
$8,074.52
|
| Rate for Payer: United Healthcare All Payer |
$7,401.64
|
|
|
COUPLER MINI MALE TO MALE 4MM
|
Facility
|
OP
|
$8,410.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.42 |
| Max. Negotiated Rate |
$8,074.52 |
| Rate for Payer: Aetna Commercial |
$6,476.44
|
| Rate for Payer: Anthem Medicaid |
$2,892.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,560.55
|
| Rate for Payer: Cash Price |
$4,205.48
|
| Rate for Payer: Cigna Commercial |
$6,981.10
|
| Rate for Payer: First Health Commercial |
$7,990.41
|
| Rate for Payer: Humana Commercial |
$7,149.32
|
| Rate for Payer: Humana KY Medicaid |
$2,892.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,921.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,896.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,207.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,523.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,950.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,401.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,308.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,682.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,093.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,607.40
|
| Rate for Payer: PHCS Commercial |
$8,074.52
|
| Rate for Payer: United Healthcare All Payer |
$7,401.64
|
|
|
COUPLER MINI MALE TO MALE 6MM
|
Facility
|
OP
|
$8,410.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.42 |
| Max. Negotiated Rate |
$8,074.52 |
| Rate for Payer: Aetna Commercial |
$6,476.44
|
| Rate for Payer: Anthem Medicaid |
$2,892.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,560.55
|
| Rate for Payer: Cash Price |
$4,205.48
|
| Rate for Payer: Cigna Commercial |
$6,981.10
|
| Rate for Payer: First Health Commercial |
$7,990.41
|
| Rate for Payer: Humana Commercial |
$7,149.32
|
| Rate for Payer: Humana KY Medicaid |
$2,892.53
|
| Rate for Payer: Kentucky WC Medicaid |
$2,921.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,896.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,207.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,523.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,950.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,401.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,308.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,682.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,093.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,607.40
|
| Rate for Payer: PHCS Commercial |
$8,074.52
|
| Rate for Payer: United Healthcare All Payer |
$7,401.64
|
|
|
COUPLER MINI MALE TO MALE 6MM
|
Facility
|
IP
|
$8,410.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,093.42 |
| Max. Negotiated Rate |
$8,074.52 |
| Rate for Payer: Aetna Commercial |
$6,476.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,560.55
|
| Rate for Payer: Cash Price |
$4,205.48
|
| Rate for Payer: Cigna Commercial |
$6,981.10
|
| Rate for Payer: First Health Commercial |
$7,990.41
|
| Rate for Payer: Humana Commercial |
$7,149.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,896.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,207.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,523.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,401.64
|
| Rate for Payer: Ohio Health Group HMO |
$6,308.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,682.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,093.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,607.40
|
| Rate for Payer: PHCS Commercial |
$8,074.52
|
| Rate for Payer: United Healthcare All Payer |
$7,401.64
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
IP
|
$346.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
25004429
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$332.16 |
| Rate for Payer: Aetna Commercial |
$266.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$269.88
|
| Rate for Payer: Cash Price |
$173.00
|
| Rate for Payer: Cigna Commercial |
$287.18
|
| Rate for Payer: First Health Commercial |
$328.70
|
| Rate for Payer: Humana Commercial |
$294.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$283.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$255.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$103.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$304.48
|
| Rate for Payer: Ohio Health Group HMO |
$259.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.26
|
| Rate for Payer: PHCS Commercial |
$332.16
|
| Rate for Payer: United Healthcare All Payer |
$304.48
|
|
|
COV5-11/23-24 PFIZER
|
Facility
|
OP
|
$340.00
|
|
|
Service Code
|
HCPCS 91319
|
| Hospital Charge Code |
77000091
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem Medicaid |
$116.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$265.20
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Humana KY Medicaid |
$116.93
|
| Rate for Payer: Kentucky WC Medicaid |
$118.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$119.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.40
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
