|
ENDURANT AAA BIFUR 36*16*145
|
Facility
|
IP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*16*145
|
Facility
|
OP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem Medicaid |
$14,583.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Humana KY Medicaid |
$14,583.51
|
| Rate for Payer: Kentucky WC Medicaid |
$14,731.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,876.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*16*166
|
Facility
|
IP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*16*166
|
Facility
|
OP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem Medicaid |
$14,583.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Humana KY Medicaid |
$14,583.51
|
| Rate for Payer: Kentucky WC Medicaid |
$14,731.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,876.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*20*145
|
Facility
|
IP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*20*145
|
Facility
|
OP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem Medicaid |
$14,583.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Humana KY Medicaid |
$14,583.51
|
| Rate for Payer: Kentucky WC Medicaid |
$14,731.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,876.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*20*166
|
Facility
|
OP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem Medicaid |
$14,583.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Humana KY Medicaid |
$14,583.51
|
| Rate for Payer: Kentucky WC Medicaid |
$14,731.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$14,876.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT AAA BIFUR 36*20*166
|
Facility
|
IP
|
$42,406.25
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$12,721.88 |
| Max. Negotiated Rate |
$40,710.00 |
| Rate for Payer: Aetna Commercial |
$32,652.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$33,076.88
|
| Rate for Payer: Cash Price |
$21,203.12
|
| Rate for Payer: Cigna Commercial |
$35,197.19
|
| Rate for Payer: First Health Commercial |
$40,285.94
|
| Rate for Payer: Humana Commercial |
$36,045.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$34,773.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$31,295.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12,721.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$37,317.50
|
| Rate for Payer: Ohio Health Group HMO |
$31,804.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33,925.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$36,893.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$29,260.31
|
| Rate for Payer: PHCS Commercial |
$40,710.00
|
| Rate for Payer: United Healthcare All Payer |
$37,317.50
|
|
|
ENDURANT II STENT GRAFT SYSTEM
|
Facility
|
IP
|
$33,968.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,190.62 |
| Max. Negotiated Rate |
$32,610.00 |
| Rate for Payer: Aetna Commercial |
$26,155.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,495.62
|
| Rate for Payer: Cash Price |
$16,984.38
|
| Rate for Payer: Cigna Commercial |
$28,194.06
|
| Rate for Payer: First Health Commercial |
$32,270.31
|
| Rate for Payer: Humana Commercial |
$28,873.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,854.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,068.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,190.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,892.50
|
| Rate for Payer: Ohio Health Group HMO |
$25,476.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,552.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,438.44
|
| Rate for Payer: PHCS Commercial |
$32,610.00
|
| Rate for Payer: United Healthcare All Payer |
$29,892.50
|
|
|
ENDURANT II STENT GRAFT SYSTEM
|
Facility
|
OP
|
$33,968.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,190.62 |
| Max. Negotiated Rate |
$32,610.00 |
| Rate for Payer: Aetna Commercial |
$26,155.94
|
| Rate for Payer: Anthem Medicaid |
$11,681.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26,495.62
|
| Rate for Payer: Cash Price |
$16,984.38
|
| Rate for Payer: Cigna Commercial |
$28,194.06
|
| Rate for Payer: First Health Commercial |
$32,270.31
|
| Rate for Payer: Humana Commercial |
$28,873.44
|
| Rate for Payer: Humana KY Medicaid |
$11,681.85
|
| Rate for Payer: Kentucky WC Medicaid |
$11,800.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27,854.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25,068.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10,190.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$11,916.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$29,892.50
|
| Rate for Payer: Ohio Health Group HMO |
$25,476.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27,175.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$29,552.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,438.44
|
| Rate for Payer: PHCS Commercial |
$32,610.00
|
| Rate for Payer: United Healthcare All Payer |
$29,892.50
|
|
|
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 |
$631.50 |
| 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 |
$1,684.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,831.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,452.45
|
| Rate for Payer: PHCS Commercial |
$2,020.80
|
| Rate for Payer: United Healthcare All Payer |
$1,852.40
|
|
|
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 |
$631.50 |
| 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 |
$1,684.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,831.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,452.45
|
| 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: Ambetter Exchange |
$1,710.00
|
| Rate for Payer: Anthem Medicaid |
$1,488.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,710.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,710.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,052.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,710.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,710.00
|
| 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 |
$2,223.00
|
| Rate for Payer: UHCCP Medicaid |
$736.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,502.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,710.00
|
|
|
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: Ambetter Exchange |
$1,710.00
|
| Rate for Payer: Anthem Medicaid |
$1,488.10
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,710.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,710.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,052.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$1,710.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,710.00
|
| 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 |
$2,223.00
|
| Rate for Payer: UHCCP Medicaid |
$736.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,502.98
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,710.00
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
IP
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
636T0007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$177.12 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.91
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna Commercial |
$153.13
|
| Rate for Payer: First Health Commercial |
$175.28
|
| Rate for Payer: Humana Commercial |
$156.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.36
|
| Rate for Payer: Ohio Health Group HMO |
$138.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.31
|
| Rate for Payer: PHCS Commercial |
$177.12
|
| Rate for Payer: United Healthcare All Payer |
$162.36
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
IP
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
25000046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$177.12 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.91
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna Commercial |
$153.13
|
| Rate for Payer: First Health Commercial |
$175.28
|
| Rate for Payer: Humana Commercial |
$156.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.36
|
| Rate for Payer: Ohio Health Group HMO |
$138.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.31
|
| Rate for Payer: PHCS Commercial |
$177.12
|
| Rate for Payer: United Healthcare All Payer |
$162.36
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
OP
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
636T0007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$177.12 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Anthem Medicaid |
$63.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.91
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna Commercial |
$153.13
|
| Rate for Payer: First Health Commercial |
$175.28
|
| Rate for Payer: Humana Commercial |
$156.82
|
| Rate for Payer: Humana KY Medicaid |
$63.45
|
| Rate for Payer: Kentucky WC Medicaid |
$64.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.36
|
| Rate for Payer: Ohio Health Group HMO |
$138.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.31
|
| Rate for Payer: PHCS Commercial |
$177.12
|
| Rate for Payer: United Healthcare All Payer |
$162.36
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
OP
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
25000046
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$177.12 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Anthem Medicaid |
$63.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.91
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna Commercial |
$153.13
|
| Rate for Payer: First Health Commercial |
$175.28
|
| Rate for Payer: Humana Commercial |
$156.82
|
| Rate for Payer: Humana KY Medicaid |
$63.45
|
| Rate for Payer: Kentucky WC Medicaid |
$64.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.36
|
| Rate for Payer: Ohio Health Group HMO |
$138.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.31
|
| Rate for Payer: PHCS Commercial |
$177.12
|
| Rate for Payer: United Healthcare All Payer |
$162.36
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
OP
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
63600007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$177.12 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Anthem Medicaid |
$63.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.91
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna Commercial |
$153.13
|
| Rate for Payer: First Health Commercial |
$175.28
|
| Rate for Payer: Humana Commercial |
$156.82
|
| Rate for Payer: Humana KY Medicaid |
$63.45
|
| Rate for Payer: Kentucky WC Medicaid |
$64.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$64.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.36
|
| Rate for Payer: Ohio Health Group HMO |
$138.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.31
|
| Rate for Payer: PHCS Commercial |
$177.12
|
| Rate for Payer: United Healthcare All Payer |
$162.36
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Facility
|
IP
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
63600007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.35 |
| Max. Negotiated Rate |
$177.12 |
| Rate for Payer: Aetna Commercial |
$142.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$143.91
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cigna Commercial |
$153.13
|
| Rate for Payer: First Health Commercial |
$175.28
|
| Rate for Payer: Humana Commercial |
$156.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$151.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$136.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$162.36
|
| Rate for Payer: Ohio Health Group HMO |
$138.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$147.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$160.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$127.31
|
| Rate for Payer: PHCS Commercial |
$177.12
|
| Rate for Payer: United Healthcare All Payer |
$162.36
|
|
|
ENGERIX-B 10MCG (HEPATITIS B)
|
Professional
|
Both
|
$184.50
|
|
|
Service Code
|
HCPCS 90744
|
| Hospital Charge Code |
63600007
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.22 |
| Max. Negotiated Rate |
$110.70 |
| Rate for Payer: Ambetter Exchange |
$31.67
|
| Rate for Payer: Anthem Medicaid |
$24.22
|
| Rate for Payer: Buckeye Individual/Medicaid |
$31.67
|
| Rate for Payer: Buckeye Medicare Advantage |
$31.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.00
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Cash Price |
$92.25
|
| Rate for Payer: Healthspan PPO |
$32.89
|
| Rate for Payer: Humana Medicaid |
$24.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$41.88
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$31.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$31.67
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$24.70
|
| Rate for Payer: Molina Healthcare Passport |
$24.22
|
| Rate for Payer: Multiplan PHCS |
$110.70
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$41.17
|
| Rate for Payer: UHCCP Medicaid |
$64.58
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$24.46
|
| Rate for Payer: Wellcare Medicare Advantage |
$31.67
|
|
|
ENGLISH PLANTAIN IGE
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$20.70 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
ENGLISH PLANTAIN IGE
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
HCPCS 86003
|
| Hospital Charge Code |
30000754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$66.24 |
| Rate for Payer: Aetna Commercial |
$53.13
|
| Rate for Payer: Anthem Medicaid |
$5.22
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$55.41
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.22
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cash Price |
$34.50
|
| Rate for Payer: Cigna Commercial |
$57.27
|
| Rate for Payer: First Health Commercial |
$65.55
|
| Rate for Payer: Humana Commercial |
$58.65
|
| 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 |
$56.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$5.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$60.72
|
| Rate for Payer: Ohio Health Group HMO |
$51.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$55.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$60.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$47.61
|
| Rate for Payer: PHCS Commercial |
$66.24
|
| Rate for Payer: United Healthcare All Payer |
$60.72
|
|
|
ENHERTU 1mg (100mg SDV)
|
Facility
|
IP
|
$15,994.39
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
25004352
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,798.32 |
| Max. Negotiated Rate |
$15,354.61 |
| Rate for Payer: Aetna Commercial |
$12,315.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,475.62
|
| Rate for Payer: Cash Price |
$7,997.20
|
| Rate for Payer: Cigna Commercial |
$13,275.34
|
| Rate for Payer: First Health Commercial |
$15,194.67
|
| Rate for Payer: Humana Commercial |
$13,595.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,115.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,803.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,798.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,075.06
|
| Rate for Payer: Ohio Health Group HMO |
$11,995.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,795.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,915.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,036.13
|
| Rate for Payer: PHCS Commercial |
$15,354.61
|
| Rate for Payer: United Healthcare All Payer |
$14,075.06
|
|
|
ENHERTU 1mg (100mg SDV)
|
Facility
|
OP
|
$15,994.39
|
|
|
Service Code
|
HCPCS J9358
|
| Hospital Charge Code |
25004352
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$15,354.61 |
| Rate for Payer: Aetna Commercial |
$12,315.68
|
| Rate for Payer: Anthem Medicaid |
$5,500.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$30.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,475.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$42.00
|
| Rate for Payer: CareSource Just4Me Medicare |
$40.50
|
| Rate for Payer: Cash Price |
$7,997.20
|
| Rate for Payer: Cash Price |
$7,997.20
|
| Rate for Payer: Cigna Commercial |
$13,275.34
|
| Rate for Payer: First Health Commercial |
$15,194.67
|
| Rate for Payer: Humana Commercial |
$13,595.23
|
| Rate for Payer: Humana KY Medicaid |
$5,500.47
|
| Rate for Payer: Humana Medicare Advantage |
$30.00
|
| Rate for Payer: Kentucky WC Medicaid |
$5,556.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,115.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,803.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,610.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,075.06
|
| Rate for Payer: Ohio Health Group HMO |
$11,995.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,795.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,915.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,036.13
|
| Rate for Payer: PHCS Commercial |
$15,354.61
|
| Rate for Payer: United Healthcare All Payer |
$14,075.06
|
|
