|
DIPRIVAN 10MG/ML (1000MGV)
|
Facility
|
OP
|
$185.21
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
25002326
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.56 |
| Max. Negotiated Rate |
$177.80 |
| Rate for Payer: Aetna Commercial |
$142.61
|
| Rate for Payer: Anthem Medicaid |
$63.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$144.46
|
| Rate for Payer: Cash Price |
$92.61
|
| Rate for Payer: Cigna Commercial |
$153.72
|
| Rate for Payer: First Health Commercial |
$175.95
|
| Rate for Payer: Humana Commercial |
$157.43
|
| Rate for Payer: Humana KY Medicaid |
$63.69
|
| Rate for Payer: Kentucky WC Medicaid |
$64.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.87
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.98
|
| Rate for Payer: Ohio Health Group HMO |
$138.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$148.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$161.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.79
|
| Rate for Payer: PHCS Commercial |
$177.80
|
| Rate for Payer: United Healthcare All Payer |
$162.98
|
|
|
DIPROLENE 0.05% 15GM CREAM
|
Facility
|
OP
|
$12.23
|
|
|
Service Code
|
NDC 472038015
|
| Hospital Charge Code |
25000571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: Anthem Medicaid |
$4.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.54
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna Commercial |
$10.15
|
| Rate for Payer: First Health Commercial |
$11.62
|
| Rate for Payer: Humana Commercial |
$10.40
|
| Rate for Payer: Humana KY Medicaid |
$4.21
|
| Rate for Payer: Kentucky WC Medicaid |
$4.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.76
|
| Rate for Payer: Ohio Health Group HMO |
$9.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.44
|
| Rate for Payer: PHCS Commercial |
$11.74
|
| Rate for Payer: United Healthcare All Payer |
$10.76
|
|
|
DIPROLENE 0.05% 15GM CREAM
|
Facility
|
IP
|
$12.23
|
|
|
Service Code
|
NDC 472038015
|
| Hospital Charge Code |
25000571
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.67 |
| Max. Negotiated Rate |
$11.74 |
| Rate for Payer: Aetna Commercial |
$9.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9.54
|
| Rate for Payer: Cash Price |
$6.12
|
| Rate for Payer: Cigna Commercial |
$10.15
|
| Rate for Payer: First Health Commercial |
$11.62
|
| Rate for Payer: Humana Commercial |
$10.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$10.76
|
| Rate for Payer: Ohio Health Group HMO |
$9.17
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.44
|
| Rate for Payer: PHCS Commercial |
$11.74
|
| Rate for Payer: United Healthcare All Payer |
$10.76
|
|
|
DIPROLENE (BETAMETHASONE) 15GM
|
Facility
|
OP
|
$19.19
|
|
|
Service Code
|
NDC 472038215
|
| Hospital Charge Code |
25003024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$18.42 |
| Rate for Payer: Aetna Commercial |
$14.78
|
| Rate for Payer: Anthem Medicaid |
$6.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.97
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$15.93
|
| Rate for Payer: First Health Commercial |
$18.23
|
| Rate for Payer: Humana Commercial |
$16.31
|
| Rate for Payer: Humana KY Medicaid |
$6.60
|
| Rate for Payer: Kentucky WC Medicaid |
$6.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$6.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.89
|
| Rate for Payer: Ohio Health Group HMO |
$14.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.24
|
| Rate for Payer: PHCS Commercial |
$18.42
|
| Rate for Payer: United Healthcare All Payer |
$16.89
|
|
|
DIPROLENE (BETAMETHASONE) 15GM
|
Facility
|
IP
|
$19.19
|
|
|
Service Code
|
NDC 472038215
|
| Hospital Charge Code |
25003024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$18.42 |
| Rate for Payer: Aetna Commercial |
$14.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14.97
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cigna Commercial |
$15.93
|
| Rate for Payer: First Health Commercial |
$18.23
|
| Rate for Payer: Humana Commercial |
$16.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$16.89
|
| Rate for Payer: Ohio Health Group HMO |
$14.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13.24
|
| Rate for Payer: PHCS Commercial |
$18.42
|
| Rate for Payer: United Healthcare All Payer |
$16.89
|
|
|
DIRECT ADVANCED LIFE SUPPORT
|
Facility
|
OP
|
$453.00
|
|
|
Service Code
|
HCPCS 99288
|
| Hospital Charge Code |
45000008
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$434.88 |
| Rate for Payer: Aetna Commercial |
$348.81
|
| Rate for Payer: Anthem Medicaid |
$155.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$353.34
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$375.99
|
| Rate for Payer: First Health Commercial |
$430.35
|
| Rate for Payer: Humana Commercial |
$385.05
|
| Rate for Payer: Humana KY Medicaid |
$155.79
|
| Rate for Payer: Kentucky WC Medicaid |
$157.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$371.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$334.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$158.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$398.64
|
| Rate for Payer: Ohio Health Group HMO |
$339.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$394.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.57
|
| Rate for Payer: PHCS Commercial |
$434.88
|
| Rate for Payer: United Healthcare All Payer |
$398.64
|
|
|
DIRECT ADVANCED LIFE SUPPORT
|
Facility
|
IP
|
$453.00
|
|
|
Service Code
|
HCPCS 99288
|
| Hospital Charge Code |
45000008
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$135.90 |
| Max. Negotiated Rate |
$434.88 |
| Rate for Payer: Aetna Commercial |
$348.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$353.34
|
| Rate for Payer: Cash Price |
$226.50
|
| Rate for Payer: Cigna Commercial |
$375.99
|
| Rate for Payer: First Health Commercial |
$430.35
|
| Rate for Payer: Humana Commercial |
$385.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$371.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$334.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$135.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$398.64
|
| Rate for Payer: Ohio Health Group HMO |
$339.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$362.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$394.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$312.57
|
| Rate for Payer: PHCS Commercial |
$434.88
|
| Rate for Payer: United Healthcare All Payer |
$398.64
|
|
|
DIRECT COOMBS IGG
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
30001230
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.45
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.96
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
DIRECT COOMBS IGG
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
HCPCS 86880
|
| Hospital Charge Code |
30001230
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$80.64 |
| Rate for Payer: Aetna Commercial |
$64.68
|
| Rate for Payer: Anthem Medicaid |
$54.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$54.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.45
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$76.83
|
| Rate for Payer: CareSource Just4Me Medicare |
$54.88
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cash Price |
$42.00
|
| Rate for Payer: Cigna Commercial |
$69.72
|
| Rate for Payer: First Health Commercial |
$79.80
|
| Rate for Payer: Humana Commercial |
$71.40
|
| Rate for Payer: Humana KY Medicaid |
$54.88
|
| Rate for Payer: Humana Medicare Advantage |
$54.88
|
| Rate for Payer: Kentucky WC Medicaid |
$55.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$68.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$61.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$65.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$73.92
|
| Rate for Payer: Ohio Health Group HMO |
$63.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$57.96
|
| Rate for Payer: PHCS Commercial |
$80.64
|
| Rate for Payer: United Healthcare All Payer |
$73.92
|
|
|
DIRECT REPAIR OF ANEURYSM - (P
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35132
|
| Hospital Charge Code |
761P1364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$2,993.88 |
| Rate for Payer: Aetna Commercial |
$2,993.88
|
| Rate for Payer: Ambetter Exchange |
$1,538.68
|
| Rate for Payer: Anthem Medicaid |
$1,186.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,538.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,538.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,846.42
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,847.75
|
| Rate for Payer: Healthspan PPO |
$2,943.57
|
| Rate for Payer: Humana Medicaid |
$1,186.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,281.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,538.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,538.68
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,210.36
|
| Rate for Payer: Molina Healthcare Passport |
$1,186.63
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,000.28
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,198.50
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,538.68
|
|
|
DIRECT REPAIR OF ANEURYSM - (P
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35081
|
| Hospital Charge Code |
761P1358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,045.78 |
| Rate for Payer: Aetna Commercial |
$3,045.78
|
| Rate for Payer: Ambetter Exchange |
$1,621.97
|
| Rate for Payer: Anthem Medicaid |
$1,326.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,621.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,621.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,946.36
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,853.78
|
| Rate for Payer: Healthspan PPO |
$2,994.60
|
| Rate for Payer: Humana Medicaid |
$1,326.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,403.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,621.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,621.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,353.40
|
| Rate for Payer: Molina Healthcare Passport |
$1,326.86
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,108.56
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,340.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,621.97
|
|
|
DIRECT REPAIR OF ANEURYSM - (P
|
Professional
|
Both
|
$4,000.00
|
|
|
Service Code
|
HCPCS 35091
|
| Hospital Charge Code |
761P1360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,400.00 |
| Max. Negotiated Rate |
$3,256.66 |
| Rate for Payer: Aetna Commercial |
$3,256.66
|
| Rate for Payer: Ambetter Exchange |
$1,673.31
|
| Rate for Payer: Anthem Medicaid |
$1,535.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,673.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,673.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,007.97
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,122.13
|
| Rate for Payer: Healthspan PPO |
$3,201.93
|
| Rate for Payer: Humana Medicaid |
$1,535.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,480.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,673.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,566.60
|
| Rate for Payer: Molina Healthcare Passport |
$1,535.88
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,175.30
|
| Rate for Payer: UHCCP Medicaid |
$1,400.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,551.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,673.31
|
|
|
DIRECT REPAIR OF ANEURYSM - (P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35141
|
| Hospital Charge Code |
761P1365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$853.95 |
| Max. Negotiated Rate |
$1,966.33 |
| Rate for Payer: Aetna Commercial |
$1,966.33
|
| Rate for Payer: Ambetter Exchange |
$1,024.58
|
| Rate for Payer: Anthem Medicaid |
$853.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,024.58
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,024.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,229.50
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$1,887.69
|
| Rate for Payer: Healthspan PPO |
$1,933.29
|
| Rate for Payer: Humana Medicaid |
$853.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,519.44
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,024.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,024.58
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$871.03
|
| Rate for Payer: Molina Healthcare Passport |
$853.95
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,331.95
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$862.49
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,024.58
|
|
|
DIRECT REPAIR OF ANEURYSM - (P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
761P1361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$980.00 |
| Max. Negotiated Rate |
$3,310.02 |
| Rate for Payer: Aetna Commercial |
$3,310.02
|
| Rate for Payer: Ambetter Exchange |
$1,762.80
|
| Rate for Payer: Anthem Medicaid |
$1,386.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,762.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,762.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,115.36
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$3,104.53
|
| Rate for Payer: Healthspan PPO |
$3,254.39
|
| Rate for Payer: Humana Medicaid |
$1,386.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,596.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,762.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,762.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,414.63
|
| Rate for Payer: Molina Healthcare Passport |
$1,386.89
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,291.64
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,400.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,762.80
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35141
|
| Hospital Charge Code |
76101365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35132
|
| Hospital Charge Code |
76101364
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
76101361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Professional
|
Both
|
$4,000.00
|
|
|
Service Code
|
HCPCS 35091
|
| Hospital Charge Code |
76101360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,400.00 |
| Max. Negotiated Rate |
$3,256.66 |
| Rate for Payer: Aetna Commercial |
$3,256.66
|
| Rate for Payer: Ambetter Exchange |
$1,673.31
|
| Rate for Payer: Anthem Medicaid |
$1,535.88
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,673.31
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,673.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,007.97
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,122.13
|
| Rate for Payer: Healthspan PPO |
$3,201.93
|
| Rate for Payer: Humana Medicaid |
$1,535.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,480.90
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,673.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,673.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,566.60
|
| Rate for Payer: Molina Healthcare Passport |
$1,535.88
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,175.30
|
| Rate for Payer: UHCCP Medicaid |
$1,400.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,551.24
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,673.31
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35081
|
| Hospital Charge Code |
76101358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 35091
|
| Hospital Charge Code |
76101360
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,200.00 |
| Max. Negotiated Rate |
$3,840.00 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,480.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,760.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
76101361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Professional
|
Both
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35081
|
| Hospital Charge Code |
76101358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,120.00 |
| Max. Negotiated Rate |
$3,045.78 |
| Rate for Payer: Aetna Commercial |
$3,045.78
|
| Rate for Payer: Ambetter Exchange |
$1,621.97
|
| Rate for Payer: Anthem Medicaid |
$1,326.86
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,621.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,621.97
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,946.36
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,853.78
|
| Rate for Payer: Healthspan PPO |
$2,994.60
|
| Rate for Payer: Humana Medicaid |
$1,326.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,403.02
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,621.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,621.97
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,353.40
|
| Rate for Payer: Molina Healthcare Passport |
$1,326.86
|
| Rate for Payer: Multiplan PHCS |
$1,920.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,108.56
|
| Rate for Payer: UHCCP Medicaid |
$1,120.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,340.13
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,621.97
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS 35081
|
| Hospital Charge Code |
76101358
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem Medicaid |
$1,100.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Humana KY Medicaid |
$1,100.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,111.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,122.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Facility
|
OP
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35141
|
| Hospital Charge Code |
76101365
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$840.00 |
| Max. Negotiated Rate |
$2,688.00 |
| Rate for Payer: Aetna Commercial |
$2,156.00
|
| Rate for Payer: Anthem Medicaid |
$962.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,184.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$2,324.00
|
| Rate for Payer: First Health Commercial |
$2,660.00
|
| Rate for Payer: Humana Commercial |
$2,380.00
|
| Rate for Payer: Humana KY Medicaid |
$962.92
|
| Rate for Payer: Kentucky WC Medicaid |
$972.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,296.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,066.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$840.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$982.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,464.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,100.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,240.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,436.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,932.00
|
| Rate for Payer: PHCS Commercial |
$2,688.00
|
| Rate for Payer: United Healthcare All Payer |
$2,464.00
|
|
|
DIRECT REPAIR OF ANEURYSM - P
|
Professional
|
Both
|
$2,800.00
|
|
|
Service Code
|
HCPCS 35102
|
| Hospital Charge Code |
76101361
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$980.00 |
| Max. Negotiated Rate |
$3,310.02 |
| Rate for Payer: Aetna Commercial |
$3,310.02
|
| Rate for Payer: Ambetter Exchange |
$1,762.80
|
| Rate for Payer: Anthem Medicaid |
$1,386.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,762.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,762.80
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,115.36
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna Commercial |
$3,104.53
|
| Rate for Payer: Healthspan PPO |
$3,254.39
|
| Rate for Payer: Humana Medicaid |
$1,386.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,596.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,762.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,762.80
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,414.63
|
| Rate for Payer: Molina Healthcare Passport |
$1,386.89
|
| Rate for Payer: Multiplan PHCS |
$1,680.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,291.64
|
| Rate for Payer: UHCCP Medicaid |
$980.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,400.76
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,762.80
|
|
