|
ENDURANT AAA BIFUR 36*16*166
|
Facility
|
IP
|
$41,208.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,357.14 |
| Max. Negotiated Rate |
$39,560.40 |
| Rate for Payer: Aetna Commercial |
$31,730.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,142.82
|
| Rate for Payer: Cash Price |
$20,604.38
|
| Rate for Payer: Cigna Commercial |
$34,203.26
|
| Rate for Payer: First Health Commercial |
$39,148.31
|
| Rate for Payer: Humana Commercial |
$35,027.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,791.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,412.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,362.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,263.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,906.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,241.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,357.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,774.71
|
| Rate for Payer: PHCS Commercial |
$39,560.40
|
| Rate for Payer: United Healthcare All Payer |
$36,263.70
|
|
|
ENDURANT AAA BIFUR 36*20*145
|
Facility
|
OP
|
$41,208.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,357.14 |
| Max. Negotiated Rate |
$39,560.40 |
| Rate for Payer: Aetna Commercial |
$31,730.74
|
| Rate for Payer: Anthem Medicaid |
$14,171.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,142.82
|
| Rate for Payer: Cash Price |
$20,604.38
|
| Rate for Payer: Cigna Commercial |
$34,203.26
|
| Rate for Payer: First Health Commercial |
$39,148.31
|
| Rate for Payer: Humana Commercial |
$35,027.44
|
| Rate for Payer: Humana KY Medicaid |
$14,171.69
|
| Rate for Payer: Kentucky WC Medicaid |
$14,315.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,791.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,412.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,362.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,456.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,263.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,906.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,241.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,357.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,774.71
|
| Rate for Payer: PHCS Commercial |
$39,560.40
|
| Rate for Payer: United Healthcare All Payer |
$36,263.70
|
|
|
ENDURANT AAA BIFUR 36*20*145
|
Facility
|
IP
|
$41,208.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,357.14 |
| Max. Negotiated Rate |
$39,560.40 |
| Rate for Payer: Aetna Commercial |
$31,730.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,142.82
|
| Rate for Payer: Cash Price |
$20,604.38
|
| Rate for Payer: Cigna Commercial |
$34,203.26
|
| Rate for Payer: First Health Commercial |
$39,148.31
|
| Rate for Payer: Humana Commercial |
$35,027.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,791.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,412.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,362.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,263.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,906.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,241.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,357.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,774.71
|
| Rate for Payer: PHCS Commercial |
$39,560.40
|
| Rate for Payer: United Healthcare All Payer |
$36,263.70
|
|
|
ENDURANT AAA BIFUR 36*20*166
|
Facility
|
OP
|
$41,208.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,357.14 |
| Max. Negotiated Rate |
$39,560.40 |
| Rate for Payer: Aetna Commercial |
$31,730.74
|
| Rate for Payer: Anthem Medicaid |
$14,171.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,142.82
|
| Rate for Payer: Cash Price |
$20,604.38
|
| Rate for Payer: Cigna Commercial |
$34,203.26
|
| Rate for Payer: First Health Commercial |
$39,148.31
|
| Rate for Payer: Humana Commercial |
$35,027.44
|
| Rate for Payer: Humana KY Medicaid |
$14,171.69
|
| Rate for Payer: Kentucky WC Medicaid |
$14,315.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,791.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,412.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,362.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,456.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,263.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,906.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,241.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,357.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,774.71
|
| Rate for Payer: PHCS Commercial |
$39,560.40
|
| Rate for Payer: United Healthcare All Payer |
$36,263.70
|
|
|
ENDURANT AAA BIFUR 36*20*166
|
Facility
|
IP
|
$41,208.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,357.14 |
| Max. Negotiated Rate |
$39,560.40 |
| Rate for Payer: Aetna Commercial |
$31,730.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$32,142.82
|
| Rate for Payer: Cash Price |
$20,604.38
|
| Rate for Payer: Cigna Commercial |
$34,203.26
|
| Rate for Payer: First Health Commercial |
$39,148.31
|
| Rate for Payer: Humana Commercial |
$35,027.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$33,791.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$30,412.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,362.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$36,263.70
|
| Rate for Payer: Ohio Health Group HMO |
$30,906.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,241.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,357.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,774.71
|
| Rate for Payer: PHCS Commercial |
$39,560.40
|
| Rate for Payer: United Healthcare All Payer |
$36,263.70
|
|
|
ENDURANT II STENT GRAFT SYSTEM
|
Facility
|
OP
|
$32,996.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,289.51 |
| Max. Negotiated Rate |
$31,676.40 |
| Rate for Payer: Aetna Commercial |
$25,407.11
|
| Rate for Payer: Anthem Medicaid |
$11,347.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,737.08
|
| Rate for Payer: Cash Price |
$16,498.12
|
| Rate for Payer: Cigna Commercial |
$27,386.89
|
| Rate for Payer: First Health Commercial |
$31,346.44
|
| Rate for Payer: Humana Commercial |
$28,046.81
|
| Rate for Payer: Humana KY Medicaid |
$11,347.41
|
| Rate for Payer: Kentucky WC Medicaid |
$11,462.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,056.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,351.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,898.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,575.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,036.70
|
| Rate for Payer: Ohio Health Group HMO |
$24,747.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,599.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,289.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,228.84
|
| Rate for Payer: PHCS Commercial |
$31,676.40
|
| Rate for Payer: United Healthcare All Payer |
$29,036.70
|
|
|
ENDURANT II STENT GRAFT SYSTEM
|
Facility
|
IP
|
$32,996.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,289.51 |
| Max. Negotiated Rate |
$31,676.40 |
| Rate for Payer: Aetna Commercial |
$25,407.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25,737.08
|
| Rate for Payer: Cash Price |
$16,498.12
|
| Rate for Payer: Cigna Commercial |
$27,386.89
|
| Rate for Payer: First Health Commercial |
$31,346.44
|
| Rate for Payer: Humana Commercial |
$28,046.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,056.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24,351.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,898.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,036.70
|
| Rate for Payer: Ohio Health Group HMO |
$24,747.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,599.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,289.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,228.84
|
| Rate for Payer: PHCS Commercial |
$31,676.40
|
| Rate for Payer: United Healthcare All Payer |
$29,036.70
|
|
|
ENDVSCLR REP ILIACART ILIO-ILI
|
Facility
|
OP
|
$2,105.00
|
|
|
Service Code
|
HCPCS 34708
|
| Hospital Charge Code |
76101349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$273.65 |
| Max. Negotiated Rate |
$2,020.80 |
| Rate for Payer: Aetna Commercial |
$1,620.85
|
| Rate for Payer: Anthem Medicaid |
$723.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,641.90
|
| Rate for Payer: Cash Price |
$1,052.50
|
| Rate for Payer: Cigna Commercial |
$1,747.15
|
| Rate for Payer: First Health Commercial |
$1,999.75
|
| Rate for Payer: Humana Commercial |
$1,789.25
|
| Rate for Payer: Humana KY Medicaid |
$723.91
|
| Rate for Payer: Kentucky WC Medicaid |
$731.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,726.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,553.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$631.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$738.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,852.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,578.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$421.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$652.55
|
| Rate for Payer: PHCS Commercial |
$2,020.80
|
| Rate for Payer: United Healthcare All Payer |
$1,852.40
|
|
|
ENDVSCLR REP ILIACART ILIO-ILI
|
Professional
|
Both
|
$2,105.00
|
|
|
Service Code
|
HCPCS 34708
|
| Hospital Charge Code |
761P1349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$736.75 |
| Max. Negotiated Rate |
$3,401.58 |
| Rate for Payer: Anthem Medicaid |
$1,488.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,105.00
|
| Rate for Payer: Cash Price |
$1,052.50
|
| Rate for Payer: Cash Price |
$1,052.50
|
| Rate for Payer: Cigna Commercial |
$3,401.58
|
| Rate for Payer: Humana Medicaid |
$1,488.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,481.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,517.86
|
| Rate for Payer: Molina Healthcare Passport |
$1,488.10
|
| Rate for Payer: Multiplan PHCS |
$1,263.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,473.50
|
| Rate for Payer: UHCCP Medicaid |
$736.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,502.98
|
|
|
ENDVSCLR REP ILIACART ILIO-ILI
|
Professional
|
Both
|
$2,105.00
|
|
|
Service Code
|
HCPCS 34708
|
| Hospital Charge Code |
76101349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$736.75 |
| Max. Negotiated Rate |
$3,401.58 |
| Rate for Payer: Anthem Medicaid |
$1,488.10
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,105.00
|
| Rate for Payer: Cash Price |
$1,052.50
|
| Rate for Payer: Cash Price |
$1,052.50
|
| Rate for Payer: Cigna Commercial |
$3,401.58
|
| Rate for Payer: Humana Medicaid |
$1,488.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2,481.84
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,517.86
|
| Rate for Payer: Molina Healthcare Passport |
$1,488.10
|
| Rate for Payer: Multiplan PHCS |
$1,263.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,473.50
|
| Rate for Payer: UHCCP Medicaid |
$736.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,502.98
|
|
|
ENDVSCLR REP ILIACART ILIO-ILI
|
Facility
|
IP
|
$2,105.00
|
|
|
Service Code
|
HCPCS 34708
|
| Hospital Charge Code |
76101349
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$273.65 |
| Max. Negotiated Rate |
$2,020.80 |
| Rate for Payer: Aetna Commercial |
$1,620.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,641.90
|
| Rate for Payer: Cash Price |
$1,052.50
|
| Rate for Payer: Cigna Commercial |
$1,747.15
|
| Rate for Payer: First Health Commercial |
$1,999.75
|
| Rate for Payer: Humana Commercial |
$1,789.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,726.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,553.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$631.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,852.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,578.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$421.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$273.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$652.55
|
| Rate for Payer: PHCS Commercial |
$2,020.80
|
| Rate for Payer: United Healthcare All Payer |
$1,852.40
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
IP
|
$183.67
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
25000046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$176.32 |
| Rate for Payer: Aetna Commercial |
$141.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.26
|
| Rate for Payer: Cash Price |
$91.83
|
| Rate for Payer: Cigna Commercial |
$152.45
|
| Rate for Payer: First Health Commercial |
$174.49
|
| Rate for Payer: Humana Commercial |
$156.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.63
|
| Rate for Payer: Ohio Health Group HMO |
$137.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.94
|
| Rate for Payer: PHCS Commercial |
$176.32
|
| Rate for Payer: United Healthcare All Payer |
$161.63
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
63600007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.19 |
| Max. Negotiated Rate |
$156.48 |
| Rate for Payer: Aetna Commercial |
$125.51
|
| Rate for Payer: Anthem Medicaid |
$56.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.14
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$135.29
|
| Rate for Payer: First Health Commercial |
$154.85
|
| Rate for Payer: Humana Commercial |
$138.55
|
| Rate for Payer: Humana KY Medicaid |
$56.06
|
| Rate for Payer: Kentucky WC Medicaid |
$56.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.44
|
| Rate for Payer: Ohio Health Group HMO |
$122.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.53
|
| Rate for Payer: PHCS Commercial |
$156.48
|
| Rate for Payer: United Healthcare All Payer |
$143.44
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
63600007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.89 |
| Max. Negotiated Rate |
$163.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$163.00
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Healthspan PPO |
$32.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.88
|
| Rate for Payer: Multiplan PHCS |
$97.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$114.10
|
| Rate for Payer: UHCCP Medicaid |
$57.05
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
636T0007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.19 |
| Max. Negotiated Rate |
$156.48 |
| Rate for Payer: Aetna Commercial |
$125.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.14
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$135.29
|
| Rate for Payer: First Health Commercial |
$154.85
|
| Rate for Payer: Humana Commercial |
$138.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.44
|
| Rate for Payer: Ohio Health Group HMO |
$122.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.53
|
| Rate for Payer: PHCS Commercial |
$156.48
|
| Rate for Payer: United Healthcare All Payer |
$143.44
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
OP
|
$183.67
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
25000046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.88 |
| Max. Negotiated Rate |
$176.32 |
| Rate for Payer: Aetna Commercial |
$141.43
|
| Rate for Payer: Anthem Medicaid |
$63.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.26
|
| Rate for Payer: Cash Price |
$91.83
|
| Rate for Payer: Cigna Commercial |
$152.45
|
| Rate for Payer: First Health Commercial |
$174.49
|
| Rate for Payer: Humana Commercial |
$156.12
|
| Rate for Payer: Humana KY Medicaid |
$63.16
|
| Rate for Payer: Kentucky WC Medicaid |
$63.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$150.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$135.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$161.63
|
| Rate for Payer: Ohio Health Group HMO |
$137.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$36.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$56.94
|
| Rate for Payer: PHCS Commercial |
$176.32
|
| Rate for Payer: United Healthcare All Payer |
$161.63
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
636T0007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.19 |
| Max. Negotiated Rate |
$156.48 |
| Rate for Payer: Aetna Commercial |
$125.51
|
| Rate for Payer: Anthem Medicaid |
$56.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.14
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$135.29
|
| Rate for Payer: First Health Commercial |
$154.85
|
| Rate for Payer: Humana Commercial |
$138.55
|
| Rate for Payer: Humana KY Medicaid |
$56.06
|
| Rate for Payer: Kentucky WC Medicaid |
$56.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.44
|
| Rate for Payer: Ohio Health Group HMO |
$122.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.53
|
| Rate for Payer: PHCS Commercial |
$156.48
|
| Rate for Payer: United Healthcare All Payer |
$143.44
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
63600007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.19 |
| Max. Negotiated Rate |
$156.48 |
| Rate for Payer: Aetna Commercial |
$125.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.14
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$135.29
|
| Rate for Payer: First Health Commercial |
$154.85
|
| Rate for Payer: Humana Commercial |
$138.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.44
|
| Rate for Payer: Ohio Health Group HMO |
$122.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$32.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$50.53
|
| Rate for Payer: PHCS Commercial |
$156.48
|
| Rate for Payer: United Healthcare All Payer |
$143.44
|
|
|
ENGLISH PLANTAIN IGE
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
ENGLISH PLANTAIN IGE
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$62.40 |
| Rate for Payer: Aetna Commercial |
$50.05
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cash Price |
$32.50
|
| Rate for Payer: Cigna Commercial |
$53.95
|
| Rate for Payer: First Health Commercial |
$61.75
|
| Rate for Payer: Humana Commercial |
$55.25
|
| Rate for Payer: Humana KY Medicaid |
$5.22
|
| Rate for Payer: Humana Medicare Advantage |
$5.22
|
| Rate for Payer: Kentucky WC Medicaid |
$5.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$53.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$47.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$57.20
|
| Rate for Payer: Ohio Health Group HMO |
$48.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.15
|
| Rate for Payer: PHCS Commercial |
$62.40
|
| Rate for Payer: United Healthcare All Payer |
$57.20
|
|
|
ENHERTU 1mg (100mg SDV)
|
Facility
|
IP
|
$15,305.62
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
25004352
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,989.73 |
| Max. Negotiated Rate |
$14,693.40 |
| Rate for Payer: Aetna Commercial |
$11,785.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,938.38
|
| Rate for Payer: Cash Price |
$7,652.81
|
| Rate for Payer: Cigna Commercial |
$12,703.66
|
| Rate for Payer: First Health Commercial |
$14,540.34
|
| Rate for Payer: Humana Commercial |
$13,009.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,550.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,295.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,591.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,468.95
|
| Rate for Payer: Ohio Health Group HMO |
$11,479.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,061.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,989.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,744.74
|
| Rate for Payer: PHCS Commercial |
$14,693.40
|
| Rate for Payer: United Healthcare All Payer |
$13,468.95
|
|
|
ENHERTU 1mg (100mg SDV)
|
Facility
|
OP
|
$15,305.62
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
25004352
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.24 |
| Max. Negotiated Rate |
$14,693.40 |
| Rate for Payer: Aetna Commercial |
$11,785.33
|
| Rate for Payer: Anthem Medicaid |
$5,263.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$27.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,938.38
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$38.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$36.77
|
| Rate for Payer: Cash Price |
$7,652.81
|
| Rate for Payer: Cash Price |
$7,652.81
|
| Rate for Payer: Cigna Commercial |
$12,703.66
|
| Rate for Payer: First Health Commercial |
$14,540.34
|
| Rate for Payer: Humana Commercial |
$13,009.78
|
| Rate for Payer: Humana KY Medicaid |
$5,263.60
|
| Rate for Payer: Humana Medicare Advantage |
$27.24
|
| Rate for Payer: Kentucky WC Medicaid |
$5,317.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,550.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,295.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,369.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,468.95
|
| Rate for Payer: Ohio Health Group HMO |
$11,479.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,061.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,989.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,744.74
|
| Rate for Payer: PHCS Commercial |
$14,693.40
|
| Rate for Payer: United Healthcare All Payer |
$13,468.95
|
|
|
ENO EXPIRED NITRIC OXIDE GAS
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
46000022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$30.16 |
| Max. Negotiated Rate |
$222.72 |
| Rate for Payer: Aetna Commercial |
$178.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.96
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cigna Commercial |
$192.56
|
| Rate for Payer: First Health Commercial |
$220.40
|
| Rate for Payer: Humana Commercial |
$197.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$190.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$171.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$69.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$204.16
|
| Rate for Payer: Ohio Health Group HMO |
$174.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.92
|
| Rate for Payer: PHCS Commercial |
$222.72
|
| Rate for Payer: United Healthcare All Payer |
$204.16
|
|
|
ENO EXPIRED NITRIC OXIDE GAS
|
Professional
|
Both
|
$232.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
46000022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$232.00 |
| Rate for Payer: Aetna Commercial |
$24.72
|
| Rate for Payer: Anthem Medicaid |
$12.43
|
| Rate for Payer: Buckeye Medicare Advantage |
$232.00
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cigna Commercial |
$27.04
|
| Rate for Payer: Healthspan PPO |
$33.23
|
| Rate for Payer: Humana Medicaid |
$12.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$24.11
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.68
|
| Rate for Payer: Molina Healthcare Passport |
$12.43
|
| Rate for Payer: Multiplan PHCS |
$139.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$162.40
|
| Rate for Payer: UHCCP Medicaid |
$81.20
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.55
|
|
|
ENO EXPIRED NITRIC OXIDE GAS
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
46000022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$30.16 |
| Max. Negotiated Rate |
$222.72 |
| Rate for Payer: Aetna Commercial |
$178.64
|
| Rate for Payer: Anthem Medicaid |
$79.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$180.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.55
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.82
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cash Price |
$116.00
|
| Rate for Payer: Cigna Commercial |
$192.56
|
| Rate for Payer: First Health Commercial |
$220.40
|
| Rate for Payer: Humana Commercial |
$197.20
|
| Rate for Payer: Humana KY Medicaid |
$79.78
|
| Rate for Payer: Humana Medicare Advantage |
$34.68
|
| Rate for Payer: Kentucky WC Medicaid |
$80.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$190.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$171.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$81.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$204.16
|
| Rate for Payer: Ohio Health Group HMO |
$174.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$46.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$71.92
|
| Rate for Payer: PHCS Commercial |
$222.72
|
| Rate for Payer: United Healthcare All Payer |
$204.16
|
|
