|
DEFIB VIVA QUAD XT CRT-D DF1
|
Facility
|
OP
|
$97,900.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$29,370.00 |
| Max. Negotiated Rate |
$93,984.00 |
| Rate for Payer: Aetna Commercial |
$75,383.00
|
| Rate for Payer: Anthem Medicaid |
$33,667.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$76,362.00
|
| Rate for Payer: Cash Price |
$48,950.00
|
| Rate for Payer: Cigna Commercial |
$81,257.00
|
| Rate for Payer: First Health Commercial |
$93,005.00
|
| Rate for Payer: Humana Commercial |
$83,215.00
|
| Rate for Payer: Humana KY Medicaid |
$33,667.81
|
| Rate for Payer: Kentucky WC Medicaid |
$34,010.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$80,278.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$72,250.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$29,370.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$34,343.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$86,152.00
|
| Rate for Payer: Ohio Health Group HMO |
$73,425.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$78,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$85,173.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$67,551.00
|
| Rate for Payer: PHCS Commercial |
$93,984.00
|
| Rate for Payer: United Healthcare All Payer |
$86,152.00
|
|
|
DEFIB VIVA QUAD XT CRT-D DF4
|
Facility
|
IP
|
$90,680.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$27,204.00 |
| Max. Negotiated Rate |
$87,052.80 |
| Rate for Payer: Aetna Commercial |
$69,823.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70,730.40
|
| Rate for Payer: Cash Price |
$45,340.00
|
| Rate for Payer: Cigna Commercial |
$75,264.40
|
| Rate for Payer: First Health Commercial |
$86,146.00
|
| Rate for Payer: Humana Commercial |
$77,078.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74,357.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66,921.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27,204.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$79,798.40
|
| Rate for Payer: Ohio Health Group HMO |
$68,010.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72,544.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78,891.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62,569.20
|
| Rate for Payer: PHCS Commercial |
$87,052.80
|
| Rate for Payer: United Healthcare All Payer |
$79,798.40
|
|
|
DEFIB VIVA QUAD XT CRT-D DF4
|
Facility
|
OP
|
$90,680.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$27,204.00 |
| Max. Negotiated Rate |
$87,052.80 |
| Rate for Payer: Aetna Commercial |
$69,823.60
|
| Rate for Payer: Anthem Medicaid |
$31,184.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70,730.40
|
| Rate for Payer: Cash Price |
$45,340.00
|
| Rate for Payer: Cigna Commercial |
$75,264.40
|
| Rate for Payer: First Health Commercial |
$86,146.00
|
| Rate for Payer: Humana Commercial |
$77,078.00
|
| Rate for Payer: Humana KY Medicaid |
$31,184.85
|
| Rate for Payer: Kentucky WC Medicaid |
$31,502.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74,357.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66,921.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27,204.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$31,810.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$79,798.40
|
| Rate for Payer: Ohio Health Group HMO |
$68,010.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72,544.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$78,891.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62,569.20
|
| Rate for Payer: PHCS Commercial |
$87,052.80
|
| Rate for Payer: United Healthcare All Payer |
$79,798.40
|
|
|
DEFIB VIVA S QUAD CRT-D DF1
|
Facility
|
IP
|
$96,000.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$28,800.00 |
| Max. Negotiated Rate |
$92,160.00 |
| Rate for Payer: Aetna Commercial |
$73,920.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74,880.00
|
| Rate for Payer: Cash Price |
$48,000.00
|
| Rate for Payer: Cigna Commercial |
$79,680.00
|
| Rate for Payer: First Health Commercial |
$91,200.00
|
| Rate for Payer: Humana Commercial |
$81,600.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78,720.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70,848.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,800.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$84,480.00
|
| Rate for Payer: Ohio Health Group HMO |
$72,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83,520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66,240.00
|
| Rate for Payer: PHCS Commercial |
$92,160.00
|
| Rate for Payer: United Healthcare All Payer |
$84,480.00
|
|
|
DEFIB VIVA S QUAD CRT-D DF1
|
Facility
|
OP
|
$96,000.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$28,800.00 |
| Max. Negotiated Rate |
$92,160.00 |
| Rate for Payer: Aetna Commercial |
$73,920.00
|
| Rate for Payer: Anthem Medicaid |
$33,014.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74,880.00
|
| Rate for Payer: Cash Price |
$48,000.00
|
| Rate for Payer: Cigna Commercial |
$79,680.00
|
| Rate for Payer: First Health Commercial |
$91,200.00
|
| Rate for Payer: Humana Commercial |
$81,600.00
|
| Rate for Payer: Humana KY Medicaid |
$33,014.40
|
| Rate for Payer: Kentucky WC Medicaid |
$33,350.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78,720.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70,848.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,800.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$33,676.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$84,480.00
|
| Rate for Payer: Ohio Health Group HMO |
$72,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83,520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66,240.00
|
| Rate for Payer: PHCS Commercial |
$92,160.00
|
| Rate for Payer: United Healthcare All Payer |
$84,480.00
|
|
|
DEFIB VIVA S QUAD CRT-D DF4
|
Facility
|
IP
|
$96,000.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$28,800.00 |
| Max. Negotiated Rate |
$92,160.00 |
| Rate for Payer: Aetna Commercial |
$73,920.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74,880.00
|
| Rate for Payer: Cash Price |
$48,000.00
|
| Rate for Payer: Cigna Commercial |
$79,680.00
|
| Rate for Payer: First Health Commercial |
$91,200.00
|
| Rate for Payer: Humana Commercial |
$81,600.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78,720.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70,848.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,800.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$84,480.00
|
| Rate for Payer: Ohio Health Group HMO |
$72,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83,520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66,240.00
|
| Rate for Payer: PHCS Commercial |
$92,160.00
|
| Rate for Payer: United Healthcare All Payer |
$84,480.00
|
|
|
DEFIB VIVA S QUAD CRT-D DF4
|
Facility
|
OP
|
$96,000.00
|
|
|
Service Code
|
HCPCS C1721
|
| Hospital Charge Code |
27000003
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$28,800.00 |
| Max. Negotiated Rate |
$92,160.00 |
| Rate for Payer: Aetna Commercial |
$73,920.00
|
| Rate for Payer: Anthem Medicaid |
$33,014.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74,880.00
|
| Rate for Payer: Cash Price |
$48,000.00
|
| Rate for Payer: Cigna Commercial |
$79,680.00
|
| Rate for Payer: First Health Commercial |
$91,200.00
|
| Rate for Payer: Humana Commercial |
$81,600.00
|
| Rate for Payer: Humana KY Medicaid |
$33,014.40
|
| Rate for Payer: Kentucky WC Medicaid |
$33,350.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$78,720.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$70,848.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$28,800.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$33,676.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$84,480.00
|
| Rate for Payer: Ohio Health Group HMO |
$72,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$76,800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$83,520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$66,240.00
|
| Rate for Payer: PHCS Commercial |
$92,160.00
|
| Rate for Payer: United Healthcare All Payer |
$84,480.00
|
|
|
DEFINATIVE ANAEROBIC ID
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
HCPCS 87076
|
| Hospital Charge Code |
30001260
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$27.60 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$70.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.88
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: First Health Commercial |
$87.40
|
| Rate for Payer: Humana Commercial |
$78.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.96
|
| Rate for Payer: Ohio Health Group HMO |
$69.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.48
|
| Rate for Payer: PHCS Commercial |
$88.32
|
| Rate for Payer: United Healthcare All Payer |
$80.96
|
|
|
DEFINATIVE ANAEROBIC ID
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
HCPCS 87076
|
| Hospital Charge Code |
30001260
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$88.32 |
| Rate for Payer: Aetna Commercial |
$70.84
|
| Rate for Payer: Anthem Medicaid |
$8.08
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.08
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cash Price |
$46.00
|
| Rate for Payer: Cigna Commercial |
$76.36
|
| Rate for Payer: First Health Commercial |
$87.40
|
| Rate for Payer: Humana Commercial |
$78.20
|
| Rate for Payer: Humana KY Medicaid |
$8.08
|
| Rate for Payer: Humana Medicare Advantage |
$8.08
|
| Rate for Payer: Kentucky WC Medicaid |
$8.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$75.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.96
|
| Rate for Payer: Ohio Health Group HMO |
$69.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$73.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$63.48
|
| Rate for Payer: PHCS Commercial |
$88.32
|
| Rate for Payer: United Healthcare All Payer |
$80.96
|
|
|
DEFINITY 1.1MG/ML(1.5MG V)EAML
|
Facility
|
OP
|
$858.06
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
25002737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.42 |
| Max. Negotiated Rate |
$823.74 |
| Rate for Payer: Aetna Commercial |
$660.71
|
| Rate for Payer: Anthem Medicaid |
$295.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.29
|
| Rate for Payer: Cash Price |
$429.03
|
| Rate for Payer: Cigna Commercial |
$712.19
|
| Rate for Payer: First Health Commercial |
$815.16
|
| Rate for Payer: Humana Commercial |
$729.35
|
| Rate for Payer: Humana KY Medicaid |
$295.09
|
| Rate for Payer: Kentucky WC Medicaid |
$298.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$703.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$301.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.09
|
| Rate for Payer: Ohio Health Group HMO |
$643.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$686.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$746.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.06
|
| Rate for Payer: PHCS Commercial |
$823.74
|
| Rate for Payer: United Healthcare All Payer |
$755.09
|
|
|
DEFINITY 1.1MG/ML(1.5MG V)EAML
|
Facility
|
IP
|
$858.06
|
|
|
Service Code
|
HCPCS Q9957
|
| Hospital Charge Code |
25002737
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$257.42 |
| Max. Negotiated Rate |
$823.74 |
| Rate for Payer: Aetna Commercial |
$660.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$669.29
|
| Rate for Payer: Cash Price |
$429.03
|
| Rate for Payer: Cigna Commercial |
$712.19
|
| Rate for Payer: First Health Commercial |
$815.16
|
| Rate for Payer: Humana Commercial |
$729.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$703.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$633.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$257.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$755.09
|
| Rate for Payer: Ohio Health Group HMO |
$643.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$686.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$746.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$592.06
|
| Rate for Payer: PHCS Commercial |
$823.74
|
| Rate for Payer: United Healthcare All Payer |
$755.09
|
|
|
DEFRIB FORTIFY CD2257-40
|
Facility
|
OP
|
$81,370.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
27000004
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$24,411.00 |
| Max. Negotiated Rate |
$78,115.20 |
| Rate for Payer: Aetna Commercial |
$62,654.90
|
| Rate for Payer: Anthem Medicaid |
$27,983.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63,468.60
|
| Rate for Payer: Cash Price |
$40,685.00
|
| Rate for Payer: Cigna Commercial |
$67,537.10
|
| Rate for Payer: First Health Commercial |
$77,301.50
|
| Rate for Payer: Humana Commercial |
$69,164.50
|
| Rate for Payer: Humana KY Medicaid |
$27,983.14
|
| Rate for Payer: Kentucky WC Medicaid |
$28,267.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66,723.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60,051.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,411.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,544.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$71,605.60
|
| Rate for Payer: Ohio Health Group HMO |
$61,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65,096.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70,791.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56,145.30
|
| Rate for Payer: PHCS Commercial |
$78,115.20
|
| Rate for Payer: United Healthcare All Payer |
$71,605.60
|
|
|
DEFRIB FORTIFY CD2257-40
|
Facility
|
IP
|
$81,370.00
|
|
|
Service Code
|
HCPCS C1722
|
| Hospital Charge Code |
27000004
|
|
Hospital Revenue Code
|
275
|
| Min. Negotiated Rate |
$24,411.00 |
| Max. Negotiated Rate |
$78,115.20 |
| Rate for Payer: Aetna Commercial |
$62,654.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$63,468.60
|
| Rate for Payer: Cash Price |
$40,685.00
|
| Rate for Payer: Cigna Commercial |
$67,537.10
|
| Rate for Payer: First Health Commercial |
$77,301.50
|
| Rate for Payer: Humana Commercial |
$69,164.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$66,723.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$60,051.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,411.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$71,605.60
|
| Rate for Payer: Ohio Health Group HMO |
$61,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$65,096.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70,791.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56,145.30
|
| Rate for Payer: PHCS Commercial |
$78,115.20
|
| Rate for Payer: United Healthcare All Payer |
$71,605.60
|
|
|
DEFYNE
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200025
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
DEFYNE
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
22200025
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
DEFYNE
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
22200025
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
DELAYED BREAST PROSTHESIS
|
Facility
|
IP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19342
|
| Hospital Charge Code |
76100312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$600.00 |
| Max. Negotiated Rate |
$1,920.00 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$600.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
DELAYED BREAST PROSTHESIS
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19342
|
| Hospital Charge Code |
76100312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$651.49 |
| Max. Negotiated Rate |
$1,333.32 |
| Rate for Payer: Aetna Commercial |
$1,333.32
|
| Rate for Payer: Ambetter Exchange |
$719.92
|
| Rate for Payer: Anthem Medicaid |
$651.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$719.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$719.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.90
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,258.86
|
| Rate for Payer: Healthspan PPO |
$1,066.11
|
| Rate for Payer: Humana Medicaid |
$651.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,185.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$719.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$719.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$664.52
|
| Rate for Payer: Molina Healthcare Passport |
$651.49
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$935.90
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$658.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$719.92
|
|
|
DELAYED BREAST PROSTHESIS
|
Facility
|
OP
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19342
|
| Hospital Charge Code |
76100312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$687.80 |
| Max. Negotiated Rate |
$12,378.25 |
| Rate for Payer: Aetna Commercial |
$1,540.00
|
| Rate for Payer: Anthem Medicaid |
$687.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,841.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,560.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,378.25
|
| Rate for Payer: CareSource Just4Me Medicare |
$11,936.17
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,660.00
|
| Rate for Payer: First Health Commercial |
$1,900.00
|
| Rate for Payer: Humana Commercial |
$1,700.00
|
| Rate for Payer: Humana KY Medicaid |
$687.80
|
| Rate for Payer: Humana Medicare Advantage |
$8,841.61
|
| Rate for Payer: Kentucky WC Medicaid |
$694.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,640.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,476.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,609.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$701.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,760.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,500.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,740.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,380.00
|
| Rate for Payer: PHCS Commercial |
$1,920.00
|
| Rate for Payer: United Healthcare All Payer |
$1,760.00
|
|
|
DELAYED BREAST PROSTHESIS(P
|
Professional
|
Both
|
$2,000.00
|
|
|
Service Code
|
HCPCS 19342
|
| Hospital Charge Code |
761P0312
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$651.49 |
| Max. Negotiated Rate |
$1,333.32 |
| Rate for Payer: Aetna Commercial |
$1,333.32
|
| Rate for Payer: Ambetter Exchange |
$719.92
|
| Rate for Payer: Anthem Medicaid |
$651.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$719.92
|
| Rate for Payer: Buckeye Medicare Advantage |
$719.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$863.90
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cash Price |
$1,000.00
|
| Rate for Payer: Cigna Commercial |
$1,258.86
|
| Rate for Payer: Healthspan PPO |
$1,066.11
|
| Rate for Payer: Humana Medicaid |
$651.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,185.79
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$719.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$719.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$664.52
|
| Rate for Payer: Molina Healthcare Passport |
$651.49
|
| Rate for Payer: Multiplan PHCS |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$935.90
|
| Rate for Payer: UHCCP Medicaid |
$700.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$658.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$719.92
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F
|
Professional
|
Both
|
$7,236.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
76100202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.11 |
| Max. Negotiated Rate |
$4,342.10 |
| Rate for Payer: Aetna Commercial |
$442.63
|
| Rate for Payer: Ambetter Exchange |
$306.96
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.11
|
| Rate for Payer: Anthem Medicaid |
$192.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$306.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$306.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.35
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cigna Commercial |
$426.26
|
| Rate for Payer: Healthspan PPO |
$475.89
|
| Rate for Payer: Humana Medicaid |
$192.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$398.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$306.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$306.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.94
|
| Rate for Payer: Molina Healthcare Passport |
$192.10
|
| Rate for Payer: Multiplan PHCS |
$4,342.10
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$399.05
|
| Rate for Payer: UHCCP Medicaid |
$174.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$306.96
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F
|
Facility
|
OP
|
$7,236.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
76100202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$6,947.36 |
| Rate for Payer: Aetna Commercial |
$5,572.36
|
| Rate for Payer: Anthem Medicaid |
$2,488.75
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.73
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cigna Commercial |
$6,006.57
|
| Rate for Payer: First Health Commercial |
$6,874.99
|
| Rate for Payer: Humana Commercial |
$6,151.31
|
| Rate for Payer: Humana KY Medicaid |
$2,488.75
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,514.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,538.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.41
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,789.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,296.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,993.41
|
| Rate for Payer: PHCS Commercial |
$6,947.36
|
| Rate for Payer: United Healthcare All Payer |
$6,368.41
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F
|
Facility
|
IP
|
$7,236.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
76100202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,171.05 |
| Max. Negotiated Rate |
$6,947.36 |
| Rate for Payer: Aetna Commercial |
$5,572.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,644.73
|
| Rate for Payer: Cash Price |
$3,618.42
|
| Rate for Payer: Cigna Commercial |
$6,006.57
|
| Rate for Payer: First Health Commercial |
$6,874.99
|
| Rate for Payer: Humana Commercial |
$6,151.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,934.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,340.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,171.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,368.41
|
| Rate for Payer: Ohio Health Group HMO |
$5,427.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,789.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,296.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,993.41
|
| Rate for Payer: PHCS Commercial |
$6,947.36
|
| Rate for Payer: United Healthcare All Payer |
$6,368.41
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F(P
|
Professional
|
Both
|
$860.00
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
761P0202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$166.11 |
| Max. Negotiated Rate |
$516.00 |
| Rate for Payer: Aetna Commercial |
$442.63
|
| Rate for Payer: Ambetter Exchange |
$306.96
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$166.11
|
| Rate for Payer: Anthem Medicaid |
$192.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$306.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$306.96
|
| Rate for Payer: CareSource Just4Me Medicare |
$368.35
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cash Price |
$430.00
|
| Rate for Payer: Cigna Commercial |
$426.26
|
| Rate for Payer: Healthspan PPO |
$475.89
|
| Rate for Payer: Humana Medicaid |
$192.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$398.20
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$306.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$306.96
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$195.94
|
| Rate for Payer: Molina Healthcare Passport |
$192.10
|
| Rate for Payer: Multiplan PHCS |
$516.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$399.05
|
| Rate for Payer: UHCCP Medicaid |
$174.42
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$194.02
|
| Rate for Payer: Wellcare Medicare Advantage |
$306.96
|
|
|
DELAY FLAP F/C/C/N/AX/G/H/F(T
|
Facility
|
OP
|
$6,376.83
|
|
|
Service Code
|
HCPCS 15620
|
| Hospital Charge Code |
761T0202
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,690.17 |
| Max. Negotiated Rate |
$6,121.76 |
| Rate for Payer: Aetna Commercial |
$4,910.16
|
| Rate for Payer: Anthem Medicaid |
$2,192.99
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,690.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,973.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,366.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,281.73
|
| Rate for Payer: Cash Price |
$3,188.42
|
| Rate for Payer: Cash Price |
$3,188.42
|
| Rate for Payer: Cigna Commercial |
$5,292.77
|
| Rate for Payer: First Health Commercial |
$6,057.99
|
| Rate for Payer: Humana Commercial |
$5,420.31
|
| Rate for Payer: Humana KY Medicaid |
$2,192.99
|
| Rate for Payer: Humana Medicare Advantage |
$1,690.17
|
| Rate for Payer: Kentucky WC Medicaid |
$2,215.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,229.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,706.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,028.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,236.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,611.61
|
| Rate for Payer: Ohio Health Group HMO |
$4,782.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,101.46
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,547.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,400.01
|
| Rate for Payer: PHCS Commercial |
$6,121.76
|
| Rate for Payer: United Healthcare All Payer |
$5,611.61
|
|
