|
CUP UNIV SLD/APX HLE 76MM S28
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
CUP UNIV SLD/APX HLE 76MM S28
|
Facility
|
OP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem Medicaid |
$2,537.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Humana KY Medicaid |
$2,537.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,563.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,588.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
CUP UNIV SLD/APX HLE 78MM S28
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
CUP UNIV SLD/APX HLE 78MM S28
|
Facility
|
OP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem Medicaid |
$2,537.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Humana KY Medicaid |
$2,537.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,563.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,588.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
CUP UNIV SLD/APX HLE 80MM S28
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
CUP UNIV SLD/APX HLE 80MM S28
|
Facility
|
OP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem Medicaid |
$2,537.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Humana KY Medicaid |
$2,537.98
|
| Rate for Payer: Kentucky WC Medicaid |
$2,563.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,588.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
IP
|
$5,185.00
|
|
|
Service Code
|
HCPCS 59160
|
| Hospital Charge Code |
72000011
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,555.50 |
| Max. Negotiated Rate |
$4,977.60 |
| Rate for Payer: Aetna Commercial |
$3,992.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.30
|
| Rate for Payer: Cash Price |
$2,592.50
|
| Rate for Payer: Cigna Commercial |
$4,303.55
|
| Rate for Payer: First Health Commercial |
$4,925.75
|
| Rate for Payer: Humana Commercial |
$4,407.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,555.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,148.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,510.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,577.65
|
| Rate for Payer: PHCS Commercial |
$4,977.60
|
| Rate for Payer: United Healthcare All Payer |
$4,562.80
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
OP
|
$4,112.95
|
|
|
Service Code
|
CPT 59160
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,937.82 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
OP
|
$4,112.95
|
|
|
Service Code
|
CPT 59160
|
| Hospital Charge Code |
72000011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,937.82 |
| Max. Negotiated Rate |
$4,112.95 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
|
|
CURETTAGE, POSTPARTUM
|
Facility
|
OP
|
$5,185.00
|
|
|
Service Code
|
HCPCS 59160
|
| Hospital Charge Code |
72000011
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,783.12 |
| Max. Negotiated Rate |
$4,977.60 |
| Rate for Payer: Aetna Commercial |
$3,992.45
|
| Rate for Payer: Anthem Medicaid |
$1,783.12
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,044.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$2,592.50
|
| Rate for Payer: Cash Price |
$2,592.50
|
| Rate for Payer: Cigna Commercial |
$4,303.55
|
| Rate for Payer: First Health Commercial |
$4,925.75
|
| Rate for Payer: Humana Commercial |
$4,407.25
|
| Rate for Payer: Humana KY Medicaid |
$1,783.12
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,801.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,251.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,826.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,818.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,562.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,888.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,148.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,510.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,577.65
|
| Rate for Payer: PHCS Commercial |
$4,977.60
|
| Rate for Payer: United Healthcare All Payer |
$4,562.80
|
|
|
CURETTAGE, POSTPARTUM
|
Professional
|
Both
|
$5,185.00
|
|
|
Service Code
|
HCPCS 59160
|
| Hospital Charge Code |
72000011
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$124.38 |
| Max. Negotiated Rate |
$3,111.00 |
| Rate for Payer: Aetna Commercial |
$295.35
|
| Rate for Payer: Ambetter Exchange |
$178.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$124.38
|
| Rate for Payer: Anthem Medicaid |
$169.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$178.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$178.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$213.96
|
| Rate for Payer: Cash Price |
$2,592.50
|
| Rate for Payer: Cash Price |
$2,592.50
|
| Rate for Payer: Cigna Commercial |
$293.19
|
| Rate for Payer: Healthspan PPO |
$250.26
|
| Rate for Payer: Humana Medicaid |
$169.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$234.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$178.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.67
|
| Rate for Payer: Molina Healthcare Passport |
$169.28
|
| Rate for Payer: Multiplan PHCS |
$3,111.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.79
|
| Rate for Payer: UHCCP Medicaid |
$130.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$178.30
|
|
|
CURETTAGE, POSTPARTUM(P
|
Professional
|
Both
|
$780.00
|
|
|
Service Code
|
HCPCS 59160
|
| Hospital Charge Code |
720P0011
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$124.38 |
| Max. Negotiated Rate |
$468.00 |
| Rate for Payer: Aetna Commercial |
$295.35
|
| Rate for Payer: Ambetter Exchange |
$178.30
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$124.38
|
| Rate for Payer: Anthem Medicaid |
$169.28
|
| Rate for Payer: Buckeye Individual/Medicaid |
$178.30
|
| Rate for Payer: Buckeye Medicare Advantage |
$178.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$213.96
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cash Price |
$390.00
|
| Rate for Payer: Cigna Commercial |
$293.19
|
| Rate for Payer: Healthspan PPO |
$250.26
|
| Rate for Payer: Humana Medicaid |
$169.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$234.62
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$178.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$178.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$172.67
|
| Rate for Payer: Molina Healthcare Passport |
$169.28
|
| Rate for Payer: Multiplan PHCS |
$468.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$231.79
|
| Rate for Payer: UHCCP Medicaid |
$130.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$170.97
|
| Rate for Payer: Wellcare Medicare Advantage |
$178.30
|
|
|
CURETTAGE, POSTPARTUM(T
|
Facility
|
OP
|
$4,405.00
|
|
|
Service Code
|
HCPCS 59160
|
| Hospital Charge Code |
720T0011
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,514.88 |
| Max. Negotiated Rate |
$4,228.80 |
| Rate for Payer: Aetna Commercial |
$3,391.85
|
| Rate for Payer: Anthem Medicaid |
$1,514.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,937.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,435.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,112.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,966.06
|
| Rate for Payer: Cash Price |
$2,202.50
|
| Rate for Payer: Cash Price |
$2,202.50
|
| Rate for Payer: Cigna Commercial |
$3,656.15
|
| Rate for Payer: First Health Commercial |
$4,184.75
|
| Rate for Payer: Humana Commercial |
$3,744.25
|
| Rate for Payer: Humana KY Medicaid |
$1,514.88
|
| Rate for Payer: Humana Medicare Advantage |
$2,937.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,530.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,612.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,250.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,525.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,545.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,876.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,303.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,524.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,832.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,039.45
|
| Rate for Payer: PHCS Commercial |
$4,228.80
|
| Rate for Payer: United Healthcare All Payer |
$3,876.40
|
|
|
CURETTAGE, POSTPARTUM(T
|
Facility
|
IP
|
$4,405.00
|
|
|
Service Code
|
HCPCS 59160
|
| Hospital Charge Code |
720T0011
|
|
Hospital Revenue Code
|
720
|
| Min. Negotiated Rate |
$1,321.50 |
| Max. Negotiated Rate |
$4,228.80 |
| Rate for Payer: Aetna Commercial |
$3,391.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,435.90
|
| Rate for Payer: Cash Price |
$2,202.50
|
| Rate for Payer: Cigna Commercial |
$3,656.15
|
| Rate for Payer: First Health Commercial |
$4,184.75
|
| Rate for Payer: Humana Commercial |
$3,744.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,612.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,250.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,321.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,876.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,303.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,524.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,832.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,039.45
|
| Rate for Payer: PHCS Commercial |
$4,228.80
|
| Rate for Payer: United Healthcare All Payer |
$3,876.40
|
|
|
CUROSURF 240 MG / 3 ML VIAL
|
Facility
|
OP
|
$1,018.09
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25002972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$305.43 |
| Max. Negotiated Rate |
$977.37 |
| Rate for Payer: Aetna Commercial |
$783.93
|
| Rate for Payer: Anthem Medicaid |
$350.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$794.11
|
| Rate for Payer: Cash Price |
$509.04
|
| Rate for Payer: Cigna Commercial |
$845.01
|
| Rate for Payer: First Health Commercial |
$967.19
|
| Rate for Payer: Humana Commercial |
$865.38
|
| Rate for Payer: Humana KY Medicaid |
$350.12
|
| Rate for Payer: Kentucky WC Medicaid |
$353.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$834.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$751.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$305.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$357.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$895.92
|
| Rate for Payer: Ohio Health Group HMO |
$763.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$814.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$702.48
|
| Rate for Payer: PHCS Commercial |
$977.37
|
| Rate for Payer: United Healthcare All Payer |
$895.92
|
|
|
CUROSURF 240 MG / 3 ML VIAL
|
Facility
|
IP
|
$1,018.09
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25002972
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$305.43 |
| Max. Negotiated Rate |
$977.37 |
| Rate for Payer: Aetna Commercial |
$783.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$794.11
|
| Rate for Payer: Cash Price |
$509.04
|
| Rate for Payer: Cigna Commercial |
$845.01
|
| Rate for Payer: First Health Commercial |
$967.19
|
| Rate for Payer: Humana Commercial |
$865.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$834.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$751.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$305.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$895.92
|
| Rate for Payer: Ohio Health Group HMO |
$763.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$814.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$702.48
|
| Rate for Payer: PHCS Commercial |
$977.37
|
| Rate for Payer: United Healthcare All Payer |
$895.92
|
|
|
CUSTODIOL PERFUSION SOLUTION
|
Facility
|
IP
|
$631.52
|
|
|
Service Code
|
NDC 25767073545
|
| Hospital Charge Code |
25002973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$189.46 |
| Max. Negotiated Rate |
$606.26 |
| Rate for Payer: Aetna Commercial |
$486.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$492.59
|
| Rate for Payer: Cash Price |
$315.76
|
| Rate for Payer: Cigna Commercial |
$524.16
|
| Rate for Payer: First Health Commercial |
$599.94
|
| Rate for Payer: Humana Commercial |
$536.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$517.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$466.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$189.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$555.74
|
| Rate for Payer: Ohio Health Group HMO |
$473.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$505.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$549.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$435.75
|
| Rate for Payer: PHCS Commercial |
$606.26
|
| Rate for Payer: United Healthcare All Payer |
$555.74
|
|
|
CUSTODIOL PERFUSION SOLUTION
|
Facility
|
OP
|
$631.52
|
|
|
Service Code
|
NDC 25767073545
|
| Hospital Charge Code |
25002973
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$189.46 |
| Max. Negotiated Rate |
$606.26 |
| Rate for Payer: Aetna Commercial |
$486.27
|
| Rate for Payer: Anthem Medicaid |
$217.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$492.59
|
| Rate for Payer: Cash Price |
$315.76
|
| Rate for Payer: Cigna Commercial |
$524.16
|
| Rate for Payer: First Health Commercial |
$599.94
|
| Rate for Payer: Humana Commercial |
$536.79
|
| Rate for Payer: Humana KY Medicaid |
$217.18
|
| Rate for Payer: Kentucky WC Medicaid |
$219.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$517.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$466.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$189.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$221.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$555.74
|
| Rate for Payer: Ohio Health Group HMO |
$473.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$505.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$549.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$435.75
|
| Rate for Payer: PHCS Commercial |
$606.26
|
| Rate for Payer: United Healthcare All Payer |
$555.74
|
|
|
CUSTOM FIT HEARING PROTECTION
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS V5299
|
| Hospital Charge Code |
47000119
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
CUSTOM FIT HEARING PROTECTION
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS V5299
|
| Hospital Charge Code |
47000119
|
|
Hospital Revenue Code
|
279
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
CUSTOM FIT HEAR PROTECT SP
|
Professional
|
Both
|
$1,500.00
|
|
| Hospital Charge Code |
47000121
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,050.00 |
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
|
|
CUSTOM HUM STEM 6*160MM
|
Facility
|
OP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem Medicaid |
$8,812.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Humana KY Medicaid |
$8,812.44
|
| Rate for Payer: Kentucky WC Medicaid |
$8,902.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,989.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
CUSTOM HUM STEM 6*160MM
|
Facility
|
IP
|
$25,625.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,687.50 |
| Max. Negotiated Rate |
$24,600.00 |
| Rate for Payer: Aetna Commercial |
$19,731.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,987.50
|
| Rate for Payer: Cash Price |
$12,812.50
|
| Rate for Payer: Cigna Commercial |
$21,268.75
|
| Rate for Payer: First Health Commercial |
$24,343.75
|
| Rate for Payer: Humana Commercial |
$21,781.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21,012.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,911.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,687.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,550.00
|
| Rate for Payer: Ohio Health Group HMO |
$19,218.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,500.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,293.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,681.25
|
| Rate for Payer: PHCS Commercial |
$24,600.00
|
| Rate for Payer: United Healthcare All Payer |
$22,550.00
|
|
|
CUSTOM SLEEVE
|
Facility
|
IP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
CUSTOM SLEEVE
|
Facility
|
OP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem Medicaid |
$1,332.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Humana KY Medicaid |
$1,332.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,346.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,359.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
