|
AFFINITY 2.5X2.5CM
|
Facility
|
OP
|
$12,242.50
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
27000257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,591.52 |
| Max. Negotiated Rate |
$11,752.80 |
| Rate for Payer: Aetna Commercial |
$9,426.72
|
| Rate for Payer: Anthem Medicaid |
$4,210.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,549.15
|
| Rate for Payer: Cash Price |
$6,121.25
|
| Rate for Payer: Cigna Commercial |
$10,161.28
|
| Rate for Payer: First Health Commercial |
$11,630.38
|
| Rate for Payer: Humana Commercial |
$10,406.12
|
| Rate for Payer: Humana KY Medicaid |
$4,210.20
|
| Rate for Payer: Kentucky WC Medicaid |
$4,253.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,038.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,034.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,672.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,294.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,773.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,181.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,448.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,591.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,795.18
|
| Rate for Payer: PHCS Commercial |
$11,752.80
|
| Rate for Payer: United Healthcare All Payer |
$10,773.40
|
|
|
AFFINITY 2.5X2.5CM
|
Facility
|
IP
|
$12,242.50
|
|
|
Service Code
|
HCPCS Q4159
|
| Hospital Charge Code |
27000257
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,591.52 |
| Max. Negotiated Rate |
$11,752.80 |
| Rate for Payer: Aetna Commercial |
$9,426.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,549.15
|
| Rate for Payer: Cash Price |
$6,121.25
|
| Rate for Payer: Cigna Commercial |
$10,161.28
|
| Rate for Payer: First Health Commercial |
$11,630.38
|
| Rate for Payer: Humana Commercial |
$10,406.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,038.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,034.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,672.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,773.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,181.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,448.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,591.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,795.18
|
| Rate for Payer: PHCS Commercial |
$11,752.80
|
| Rate for Payer: United Healthcare All Payer |
$10,773.40
|
|
|
AFFIXUS BALLNSE GUIDEWIRE 80C
|
Facility
|
IP
|
$3,180.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$413.40 |
| Max. Negotiated Rate |
$3,052.80 |
| Rate for Payer: Aetna Commercial |
$2,448.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,480.40
|
| Rate for Payer: Cash Price |
$1,590.00
|
| Rate for Payer: Cigna Commercial |
$2,639.40
|
| Rate for Payer: First Health Commercial |
$3,021.00
|
| Rate for Payer: Humana Commercial |
$2,703.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,607.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,346.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$954.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,798.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,385.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$985.80
|
| Rate for Payer: PHCS Commercial |
$3,052.80
|
| Rate for Payer: United Healthcare All Payer |
$2,798.40
|
|
|
AFFIXUS BALLNSE GUIDEWIRE 80C
|
Facility
|
OP
|
$3,180.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$413.40 |
| Max. Negotiated Rate |
$3,052.80 |
| Rate for Payer: Aetna Commercial |
$2,448.60
|
| Rate for Payer: Anthem Medicaid |
$1,093.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,480.40
|
| Rate for Payer: Cash Price |
$1,590.00
|
| Rate for Payer: Cigna Commercial |
$2,639.40
|
| Rate for Payer: First Health Commercial |
$3,021.00
|
| Rate for Payer: Humana Commercial |
$2,703.00
|
| Rate for Payer: Humana KY Medicaid |
$1,093.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,104.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,607.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,346.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$954.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,115.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,798.40
|
| Rate for Payer: Ohio Health Group HMO |
$2,385.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$636.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$413.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$985.80
|
| Rate for Payer: PHCS Commercial |
$3,052.80
|
| Rate for Payer: United Healthcare All Payer |
$2,798.40
|
|
|
AFFIXUS GUIDE PIN THRD 3.2MM
|
Facility
|
OP
|
$1,882.53
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.73 |
| Max. Negotiated Rate |
$1,807.23 |
| Rate for Payer: Aetna Commercial |
$1,449.55
|
| Rate for Payer: Anthem Medicaid |
$647.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,468.37
|
| Rate for Payer: Cash Price |
$941.26
|
| Rate for Payer: Cigna Commercial |
$1,562.50
|
| Rate for Payer: First Health Commercial |
$1,788.40
|
| Rate for Payer: Humana Commercial |
$1,600.15
|
| Rate for Payer: Humana KY Medicaid |
$647.40
|
| Rate for Payer: Kentucky WC Medicaid |
$653.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,389.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$660.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.63
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.58
|
| Rate for Payer: PHCS Commercial |
$1,807.23
|
| Rate for Payer: United Healthcare All Payer |
$1,656.63
|
|
|
AFFIXUS GUIDE PIN THRD 3.2MM
|
Facility
|
IP
|
$1,882.53
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$244.73 |
| Max. Negotiated Rate |
$1,807.23 |
| Rate for Payer: Aetna Commercial |
$1,449.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,468.37
|
| Rate for Payer: Cash Price |
$941.26
|
| Rate for Payer: Cigna Commercial |
$1,562.50
|
| Rate for Payer: First Health Commercial |
$1,788.40
|
| Rate for Payer: Humana Commercial |
$1,600.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,543.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,389.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$564.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,656.63
|
| Rate for Payer: Ohio Health Group HMO |
$1,411.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$376.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$244.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$583.58
|
| Rate for Payer: PHCS Commercial |
$1,807.23
|
| Rate for Payer: United Healthcare All Payer |
$1,656.63
|
|
|
AFFIXUS GUIDWIR BALL NOSE 100C
|
Facility
|
IP
|
$3,145.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$3,019.20 |
| Rate for Payer: Aetna Commercial |
$2,421.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,453.10
|
| Rate for Payer: Cash Price |
$1,572.50
|
| Rate for Payer: Cigna Commercial |
$2,610.35
|
| Rate for Payer: First Health Commercial |
$2,987.75
|
| Rate for Payer: Humana Commercial |
$2,673.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,578.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,321.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$943.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,767.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,358.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$629.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$408.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$974.95
|
| Rate for Payer: PHCS Commercial |
$3,019.20
|
| Rate for Payer: United Healthcare All Payer |
$2,767.60
|
|
|
AFFIXUS GUIDWIR BALL NOSE 100C
|
Facility
|
OP
|
$3,145.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$408.85 |
| Max. Negotiated Rate |
$3,019.20 |
| Rate for Payer: Aetna Commercial |
$2,421.65
|
| Rate for Payer: Anthem Medicaid |
$1,081.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,453.10
|
| Rate for Payer: Cash Price |
$1,572.50
|
| Rate for Payer: Cigna Commercial |
$2,610.35
|
| Rate for Payer: First Health Commercial |
$2,987.75
|
| Rate for Payer: Humana Commercial |
$2,673.25
|
| Rate for Payer: Humana KY Medicaid |
$1,081.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,092.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,578.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,321.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$943.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,103.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,767.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,358.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$629.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$408.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$974.95
|
| Rate for Payer: PHCS Commercial |
$3,019.20
|
| Rate for Payer: United Healthcare All Payer |
$2,767.60
|
|
|
AFLURIA PFS 24-25
|
Facility
|
IP
|
$120.25
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
25000020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$115.44 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.60
|
| Rate for Payer: Aetna Commercial |
$92.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.80
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.81
|
| Rate for Payer: First Health Commercial |
$114.24
|
| Rate for Payer: Humana Commercial |
$102.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.82
|
| Rate for Payer: Ohio Health Group HMO |
$90.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.28
|
| Rate for Payer: PHCS Commercial |
$115.44
|
| Rate for Payer: United Healthcare All Payer |
$105.82
|
|
|
AFLURIA PFS 24-25
|
Facility
|
OP
|
$120.25
|
|
|
Service Code
|
HCPCS 90656
|
| Hospital Charge Code |
25000020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.63 |
| Max. Negotiated Rate |
$115.44 |
| Rate for Payer: Aetna Commercial |
$92.59
|
| Rate for Payer: Anthem Medicaid |
$41.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.80
|
| Rate for Payer: Cash Price |
$60.12
|
| Rate for Payer: Cigna Commercial |
$99.81
|
| Rate for Payer: First Health Commercial |
$114.24
|
| Rate for Payer: Humana Commercial |
$102.21
|
| Rate for Payer: Humana KY Medicaid |
$41.35
|
| Rate for Payer: Kentucky WC Medicaid |
$41.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.82
|
| Rate for Payer: Ohio Health Group HMO |
$90.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$24.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$37.28
|
| Rate for Payer: PHCS Commercial |
$115.44
|
| Rate for Payer: United Healthcare All Payer |
$105.82
|
|
|
AFLURIA QUAD (3YR & UP)
|
Facility
|
IP
|
$126.80
|
|
|
Service Code
|
HCPCS 90686
|
| Hospital Charge Code |
77000033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$121.73 |
| Rate for Payer: Aetna Commercial |
$97.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.90
|
| Rate for Payer: Cash Price |
$63.40
|
| Rate for Payer: Cigna Commercial |
$105.24
|
| Rate for Payer: First Health Commercial |
$120.46
|
| Rate for Payer: Humana Commercial |
$107.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.58
|
| Rate for Payer: Ohio Health Group HMO |
$95.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.31
|
| Rate for Payer: PHCS Commercial |
$121.73
|
| Rate for Payer: United Healthcare All Payer |
$111.58
|
|
|
AFLURIA QUAD (3YR & UP)
|
Facility
|
IP
|
$126.80
|
|
|
Service Code
|
HCPCS 90686
|
| Hospital Charge Code |
770T0033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$121.73 |
| Rate for Payer: Aetna Commercial |
$97.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.90
|
| Rate for Payer: Cash Price |
$63.40
|
| Rate for Payer: Cigna Commercial |
$105.24
|
| Rate for Payer: First Health Commercial |
$120.46
|
| Rate for Payer: Humana Commercial |
$107.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.58
|
| Rate for Payer: Ohio Health Group HMO |
$95.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.31
|
| Rate for Payer: PHCS Commercial |
$121.73
|
| Rate for Payer: United Healthcare All Payer |
$111.58
|
|
|
AFLURIA QUAD (3YR & UP)
|
Facility
|
OP
|
$126.80
|
|
|
Service Code
|
HCPCS 90686
|
| Hospital Charge Code |
770T0033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$121.73 |
| Rate for Payer: Aetna Commercial |
$97.64
|
| Rate for Payer: Anthem Medicaid |
$43.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.90
|
| Rate for Payer: Cash Price |
$63.40
|
| Rate for Payer: Cigna Commercial |
$105.24
|
| Rate for Payer: First Health Commercial |
$120.46
|
| Rate for Payer: Humana Commercial |
$107.78
|
| Rate for Payer: Humana KY Medicaid |
$43.61
|
| Rate for Payer: Kentucky WC Medicaid |
$44.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.58
|
| Rate for Payer: Ohio Health Group HMO |
$95.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.31
|
| Rate for Payer: PHCS Commercial |
$121.73
|
| Rate for Payer: United Healthcare All Payer |
$111.58
|
|
|
AFLURIA QUAD (3YR & UP)
|
Professional
|
Both
|
$126.80
|
|
|
Service Code
|
HCPCS 90686
|
| Hospital Charge Code |
77000033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$126.80 |
| Rate for Payer: Buckeye Medicare Advantage |
$126.80
|
| Rate for Payer: Cash Price |
$63.40
|
| Rate for Payer: Cash Price |
$63.40
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$30.26
|
| Rate for Payer: Multiplan PHCS |
$76.08
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$88.76
|
| Rate for Payer: UHCCP Medicaid |
$44.38
|
|
|
AFLURIA QUAD (3YR & UP)
|
Facility
|
OP
|
$126.80
|
|
|
Service Code
|
HCPCS 90686
|
| Hospital Charge Code |
77000033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.48 |
| Max. Negotiated Rate |
$121.73 |
| Rate for Payer: Aetna Commercial |
$97.64
|
| Rate for Payer: Anthem Medicaid |
$43.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.90
|
| Rate for Payer: Cash Price |
$63.40
|
| Rate for Payer: Cigna Commercial |
$105.24
|
| Rate for Payer: First Health Commercial |
$120.46
|
| Rate for Payer: Humana Commercial |
$107.78
|
| Rate for Payer: Humana KY Medicaid |
$43.61
|
| Rate for Payer: Kentucky WC Medicaid |
$44.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$103.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$93.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$38.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$44.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$111.58
|
| Rate for Payer: Ohio Health Group HMO |
$95.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$39.31
|
| Rate for Payer: PHCS Commercial |
$121.73
|
| Rate for Payer: United Healthcare All Payer |
$111.58
|
|
|
AFRIN(OXYMETAZOLINE) 15ML SPRY
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 904700635
|
| Hospital Charge Code |
25000172
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem Medicaid |
$0.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Humana KY Medicaid |
$0.00
|
| Rate for Payer: Kentucky WC Medicaid |
$0.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
AFRIN(OXYMETAZOLINE) 15ML SPRY
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 904700635
|
| Hospital Charge Code |
25000172
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna Commercial |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.01
|
| Rate for Payer: First Health Commercial |
$0.01
|
| Rate for Payer: Humana Commercial |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.01
|
| Rate for Payer: Ohio Health Group HMO |
$0.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.00
|
| Rate for Payer: PHCS Commercial |
$0.01
|
| Rate for Payer: United Healthcare All Payer |
$0.01
|
|
|
AFTER CARE
|
Professional
|
Both
|
$175.00
|
|
| Hospital Charge Code |
22200207
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$175.00
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: Multiplan PHCS |
$105.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$122.50
|
| Rate for Payer: UHCCP Medicaid |
$61.25
|
|
|
AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC
|
Facility
|
IP
|
$13,243.55
|
|
|
Service Code
|
MSDRG 560
|
| Min. Negotiated Rate |
$8,986.70 |
| Max. Negotiated Rate |
$13,243.55 |
| Rate for Payer: Anthem Medicaid |
$8,986.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9,459.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13,243.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,770.57
|
| Rate for Payer: Humana KY Medicaid |
$8,986.70
|
| Rate for Payer: Humana Medicare Advantage |
$9,459.68
|
| Rate for Payer: Kentucky WC Medicaid |
$9,076.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11,351.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,166.43
|
|
|
AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC
|
Facility
|
IP
|
$21,647.54
|
|
|
Service Code
|
MSDRG 559
|
| Min. Negotiated Rate |
$14,689.40 |
| Max. Negotiated Rate |
$21,647.54 |
| Rate for Payer: Anthem Medicaid |
$14,689.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15,462.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$21,647.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$20,874.42
|
| Rate for Payer: Humana KY Medicaid |
$14,689.40
|
| Rate for Payer: Humana Medicare Advantage |
$15,462.53
|
| Rate for Payer: Kentucky WC Medicaid |
$14,836.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18,555.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,983.19
|
|
|
AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC
|
Facility
|
IP
|
$9,126.95
|
|
|
Service Code
|
MSDRG 561
|
| Min. Negotiated Rate |
$6,193.29 |
| Max. Negotiated Rate |
$9,126.95 |
| Rate for Payer: Anthem Medicaid |
$6,193.29
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,519.25
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,126.95
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,800.99
|
| Rate for Payer: Humana KY Medicaid |
$6,193.29
|
| Rate for Payer: Humana Medicare Advantage |
$6,519.25
|
| Rate for Payer: Kentucky WC Medicaid |
$6,255.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,823.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,317.15
|
|
|
AFTERCARE WITH CC/MCC
|
Facility
|
IP
|
$12,549.81
|
|
|
Service Code
|
MSDRG 949
|
| Min. Negotiated Rate |
$8,515.94 |
| Max. Negotiated Rate |
$12,549.81 |
| Rate for Payer: Anthem Medicaid |
$8,515.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8,964.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12,549.81
|
| Rate for Payer: CareSource Just4Me Medicare |
$12,101.60
|
| Rate for Payer: Humana KY Medicaid |
$8,515.94
|
| Rate for Payer: Humana Medicare Advantage |
$8,964.15
|
| Rate for Payer: Kentucky WC Medicaid |
$8,601.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,756.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,686.26
|
|
|
AFTERCARE WITHOUT CC/MCC
|
Facility
|
IP
|
$7,470.48
|
|
|
Service Code
|
MSDRG 950
|
| Min. Negotiated Rate |
$5,069.26 |
| Max. Negotiated Rate |
$7,470.48 |
| Rate for Payer: Anthem Medicaid |
$5,069.26
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5,336.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7,470.48
|
| Rate for Payer: CareSource Just4Me Medicare |
$7,203.68
|
| Rate for Payer: Humana KY Medicaid |
$5,069.26
|
| Rate for Payer: Humana Medicare Advantage |
$5,336.06
|
| Rate for Payer: Kentucky WC Medicaid |
$5,119.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,403.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,170.64
|
|
|
AFX 2 BFMN BDY BEA22-60/I16-40
|
Facility
|
IP
|
$83,496.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,854.53 |
| Max. Negotiated Rate |
$80,156.54 |
| Rate for Payer: Aetna Commercial |
$64,292.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,127.19
|
| Rate for Payer: Cash Price |
$41,748.20
|
| Rate for Payer: Cigna Commercial |
$69,302.01
|
| Rate for Payer: First Health Commercial |
$79,321.58
|
| Rate for Payer: Humana Commercial |
$70,971.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68,467.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,620.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,048.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$73,476.83
|
| Rate for Payer: Ohio Health Group HMO |
$62,622.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,699.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,854.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,883.88
|
| Rate for Payer: PHCS Commercial |
$80,156.54
|
| Rate for Payer: United Healthcare All Payer |
$73,476.83
|
|
|
AFX 2 BFMN BDY BEA22-60/I16-40
|
Facility
|
OP
|
$83,496.40
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,854.53 |
| Max. Negotiated Rate |
$80,156.54 |
| Rate for Payer: Aetna Commercial |
$64,292.23
|
| Rate for Payer: Anthem Medicaid |
$28,714.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$65,127.19
|
| Rate for Payer: Cash Price |
$41,748.20
|
| Rate for Payer: Cigna Commercial |
$69,302.01
|
| Rate for Payer: First Health Commercial |
$79,321.58
|
| Rate for Payer: Humana Commercial |
$70,971.94
|
| Rate for Payer: Humana KY Medicaid |
$28,714.41
|
| Rate for Payer: Kentucky WC Medicaid |
$29,006.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68,467.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61,620.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25,048.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$29,290.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$73,476.83
|
| Rate for Payer: Ohio Health Group HMO |
$62,622.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,699.28
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,854.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$25,883.88
|
| Rate for Payer: PHCS Commercial |
$80,156.54
|
| Rate for Payer: United Healthcare All Payer |
$73,476.83
|
|
