|
ENO EXPIRED NITRIC OXIDE GAS
|
Professional
|
Both
|
$244.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
46000022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$146.40 |
| Rate for Payer: Aetna Commercial |
$24.72
|
| Rate for Payer: Ambetter Exchange |
$16.54
|
| Rate for Payer: Anthem Medicaid |
$12.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.85
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cash Price |
$122.00
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$16.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.68
|
| Rate for Payer: Molina Healthcare Passport |
$12.43
|
| Rate for Payer: Multiplan PHCS |
$146.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.50
|
| Rate for Payer: UHCCP Medicaid |
$85.40
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.54
|
|
|
ENO EXPIRED NITRIC OXIDE GAS
|
Facility
|
OP
|
$244.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
46000022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem Medicaid |
$83.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$190.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.96
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Humana KY Medicaid |
$83.91
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$84.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$85.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.36
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
ENO EXPIRED NITRIC OXIDE GAS
|
Facility
|
IP
|
$244.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
46000022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$234.24 |
| Rate for Payer: Aetna Commercial |
$187.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$190.32
|
| Rate for Payer: Cash Price |
$122.00
|
| Rate for Payer: Cigna Commercial |
$202.52
|
| Rate for Payer: First Health Commercial |
$231.80
|
| Rate for Payer: Humana Commercial |
$207.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$200.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$180.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$73.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$214.72
|
| Rate for Payer: Ohio Health Group HMO |
$183.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$195.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$212.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.36
|
| Rate for Payer: PHCS Commercial |
$234.24
|
| Rate for Payer: United Healthcare All Payer |
$214.72
|
|
|
ENO EXPIRED NITRIC OXIDE GAS(P
|
Professional
|
Both
|
$45.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
460P0022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$24.72
|
| Rate for Payer: Ambetter Exchange |
$16.54
|
| Rate for Payer: Anthem Medicaid |
$12.43
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$19.85
|
| Rate for Payer: Cash Price |
$22.50
|
| Rate for Payer: Cash Price |
$22.50
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$16.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$12.68
|
| Rate for Payer: Molina Healthcare Passport |
$12.43
|
| Rate for Payer: Multiplan PHCS |
$27.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$21.50
|
| Rate for Payer: UHCCP Medicaid |
$15.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$12.55
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.54
|
|
|
ENO EXPIRED NITRIC OXIDE GAS(T
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
460T0022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$59.70 |
| Max. Negotiated Rate |
$191.04 |
| Rate for Payer: Aetna Commercial |
$153.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.22
|
| Rate for Payer: Cash Price |
$99.50
|
| Rate for Payer: Cigna Commercial |
$165.17
|
| Rate for Payer: First Health Commercial |
$189.05
|
| Rate for Payer: Humana Commercial |
$169.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.12
|
| Rate for Payer: Ohio Health Group HMO |
$149.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.31
|
| Rate for Payer: PHCS Commercial |
$191.04
|
| Rate for Payer: United Healthcare All Payer |
$175.12
|
|
|
ENO EXPIRED NITRIC OXIDE GAS(T
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
HCPCS 95012
|
| Hospital Charge Code |
460T0022
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$191.04 |
| Rate for Payer: Aetna Commercial |
$153.23
|
| Rate for Payer: Anthem Medicaid |
$68.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$36.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$155.22
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$50.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$48.96
|
| Rate for Payer: Cash Price |
$99.50
|
| Rate for Payer: Cash Price |
$99.50
|
| Rate for Payer: Cigna Commercial |
$165.17
|
| Rate for Payer: First Health Commercial |
$189.05
|
| Rate for Payer: Humana Commercial |
$169.15
|
| Rate for Payer: Humana KY Medicaid |
$68.44
|
| Rate for Payer: Humana Medicare Advantage |
$36.27
|
| Rate for Payer: Kentucky WC Medicaid |
$69.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$163.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$146.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$43.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$69.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$175.12
|
| Rate for Payer: Ohio Health Group HMO |
$149.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$159.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$173.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$137.31
|
| Rate for Payer: PHCS Commercial |
$191.04
|
| Rate for Payer: United Healthcare All Payer |
$175.12
|
|
|
ENSEAL 37CM CVD JAW
|
Facility
|
IP
|
$8,809.27
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,642.78 |
| Max. Negotiated Rate |
$8,456.90 |
| Rate for Payer: Aetna Commercial |
$6,783.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,871.23
|
| Rate for Payer: Cash Price |
$4,404.63
|
| Rate for Payer: Cigna Commercial |
$7,311.69
|
| Rate for Payer: First Health Commercial |
$8,368.81
|
| Rate for Payer: Humana Commercial |
$7,487.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,223.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,501.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,642.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,752.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,606.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,047.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,664.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,078.40
|
| Rate for Payer: PHCS Commercial |
$8,456.90
|
| Rate for Payer: United Healthcare All Payer |
$7,752.16
|
|
|
ENSEAL 37CM CVD JAW
|
Facility
|
OP
|
$8,809.27
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,642.78 |
| Max. Negotiated Rate |
$8,456.90 |
| Rate for Payer: Aetna Commercial |
$6,783.14
|
| Rate for Payer: Anthem Medicaid |
$3,029.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,871.23
|
| Rate for Payer: Cash Price |
$4,404.63
|
| Rate for Payer: Cigna Commercial |
$7,311.69
|
| Rate for Payer: First Health Commercial |
$8,368.81
|
| Rate for Payer: Humana Commercial |
$7,487.88
|
| Rate for Payer: Humana KY Medicaid |
$3,029.51
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,223.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,501.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,642.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,752.16
|
| Rate for Payer: Ohio Health Group HMO |
$6,606.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,047.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,664.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,078.40
|
| Rate for Payer: PHCS Commercial |
$8,456.90
|
| Rate for Payer: United Healthcare All Payer |
$7,752.16
|
|
|
EN SNARE 12-20MM
|
Facility
|
IP
|
$3,260.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$978.00 |
| Max. Negotiated Rate |
$3,129.60 |
| Rate for Payer: Aetna Commercial |
$2,510.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,542.80
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cigna Commercial |
$2,705.80
|
| Rate for Payer: First Health Commercial |
$3,097.00
|
| Rate for Payer: Humana Commercial |
$2,771.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,673.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,405.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$978.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,868.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,445.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,608.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,836.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,249.40
|
| Rate for Payer: PHCS Commercial |
$3,129.60
|
| Rate for Payer: United Healthcare All Payer |
$2,868.80
|
|
|
EN SNARE 12-20MM
|
Facility
|
OP
|
$3,260.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$978.00 |
| Max. Negotiated Rate |
$3,129.60 |
| Rate for Payer: Aetna Commercial |
$2,510.20
|
| Rate for Payer: Anthem Medicaid |
$1,121.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,542.80
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cigna Commercial |
$2,705.80
|
| Rate for Payer: First Health Commercial |
$3,097.00
|
| Rate for Payer: Humana Commercial |
$2,771.00
|
| Rate for Payer: Humana KY Medicaid |
$1,121.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,132.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,673.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,405.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$978.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,143.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,868.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,445.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,608.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,836.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,249.40
|
| Rate for Payer: PHCS Commercial |
$3,129.60
|
| Rate for Payer: United Healthcare All Payer |
$2,868.80
|
|
|
EN SNARE 2-4MM
|
Facility
|
OP
|
$4,475.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,342.50 |
| Max. Negotiated Rate |
$4,296.00 |
| Rate for Payer: Aetna Commercial |
$3,445.75
|
| Rate for Payer: Anthem Medicaid |
$1,538.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,490.50
|
| Rate for Payer: Cash Price |
$2,237.50
|
| Rate for Payer: Cigna Commercial |
$3,714.25
|
| Rate for Payer: First Health Commercial |
$4,251.25
|
| Rate for Payer: Humana Commercial |
$3,803.75
|
| Rate for Payer: Humana KY Medicaid |
$1,538.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,554.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,669.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,302.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,569.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,580.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,893.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,087.75
|
| Rate for Payer: PHCS Commercial |
$4,296.00
|
| Rate for Payer: United Healthcare All Payer |
$3,938.00
|
|
|
EN SNARE 2-4MM
|
Facility
|
IP
|
$4,475.00
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,342.50 |
| Max. Negotiated Rate |
$4,296.00 |
| Rate for Payer: Aetna Commercial |
$3,445.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,490.50
|
| Rate for Payer: Cash Price |
$2,237.50
|
| Rate for Payer: Cigna Commercial |
$3,714.25
|
| Rate for Payer: First Health Commercial |
$4,251.25
|
| Rate for Payer: Humana Commercial |
$3,803.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,669.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,302.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,356.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,580.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,893.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,087.75
|
| Rate for Payer: PHCS Commercial |
$4,296.00
|
| Rate for Payer: United Healthcare All Payer |
$3,938.00
|
|
|
EN SNARE 9-15MM
|
Facility
|
OP
|
$3,241.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$972.38 |
| Max. Negotiated Rate |
$3,111.60 |
| Rate for Payer: Aetna Commercial |
$2,495.76
|
| Rate for Payer: Anthem Medicaid |
$1,114.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,528.18
|
| Rate for Payer: Cash Price |
$1,620.62
|
| Rate for Payer: Cigna Commercial |
$2,690.24
|
| Rate for Payer: First Health Commercial |
$3,079.19
|
| Rate for Payer: Humana Commercial |
$2,755.06
|
| Rate for Payer: Humana KY Medicaid |
$1,114.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,126.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,657.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,392.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$972.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,137.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,852.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,430.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,593.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,819.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.46
|
| Rate for Payer: PHCS Commercial |
$3,111.60
|
| Rate for Payer: United Healthcare All Payer |
$2,852.30
|
|
|
EN SNARE 9-15MM
|
Facility
|
IP
|
$3,241.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$972.38 |
| Max. Negotiated Rate |
$3,111.60 |
| Rate for Payer: Aetna Commercial |
$2,495.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,528.18
|
| Rate for Payer: Cash Price |
$1,620.62
|
| Rate for Payer: Cigna Commercial |
$2,690.24
|
| Rate for Payer: First Health Commercial |
$3,079.19
|
| Rate for Payer: Humana Commercial |
$2,755.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,657.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,392.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$972.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,852.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,430.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,593.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,819.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.46
|
| Rate for Payer: PHCS Commercial |
$3,111.60
|
| Rate for Payer: United Healthcare All Payer |
$2,852.30
|
|
|
EN SNARE MINI 4-8
|
Facility
|
OP
|
$4,456.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,336.88 |
| Max. Negotiated Rate |
$4,278.00 |
| Rate for Payer: Aetna Commercial |
$3,431.31
|
| Rate for Payer: Anthem Medicaid |
$1,532.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,475.88
|
| Rate for Payer: Cash Price |
$2,228.12
|
| Rate for Payer: Cigna Commercial |
$3,698.69
|
| Rate for Payer: First Health Commercial |
$4,233.44
|
| Rate for Payer: Humana Commercial |
$3,787.81
|
| Rate for Payer: Humana KY Medicaid |
$1,532.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,548.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,654.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,288.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,336.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,563.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,921.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,342.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,565.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,876.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.81
|
| Rate for Payer: PHCS Commercial |
$4,278.00
|
| Rate for Payer: United Healthcare All Payer |
$3,921.50
|
|
|
EN SNARE MINI 4-8
|
Facility
|
IP
|
$4,456.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1,336.88 |
| Max. Negotiated Rate |
$4,278.00 |
| Rate for Payer: Aetna Commercial |
$3,431.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,475.88
|
| Rate for Payer: Cash Price |
$2,228.12
|
| Rate for Payer: Cigna Commercial |
$3,698.69
|
| Rate for Payer: First Health Commercial |
$4,233.44
|
| Rate for Payer: Humana Commercial |
$3,787.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,654.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,288.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,336.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,921.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,342.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,565.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,876.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.81
|
| Rate for Payer: PHCS Commercial |
$4,278.00
|
| Rate for Payer: United Healthcare All Payer |
$3,921.50
|
|
|
EN SNARE SYSTEM 30MM
|
Facility
|
OP
|
$3,241.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$972.38 |
| Max. Negotiated Rate |
$3,111.60 |
| Rate for Payer: Aetna Commercial |
$2,495.76
|
| Rate for Payer: Anthem Medicaid |
$1,114.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,528.18
|
| Rate for Payer: Cash Price |
$1,620.62
|
| Rate for Payer: Cigna Commercial |
$2,690.24
|
| Rate for Payer: First Health Commercial |
$3,079.19
|
| Rate for Payer: Humana Commercial |
$2,755.06
|
| Rate for Payer: Humana KY Medicaid |
$1,114.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,126.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,657.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,392.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$972.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,137.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,852.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,430.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,593.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,819.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.46
|
| Rate for Payer: PHCS Commercial |
$3,111.60
|
| Rate for Payer: United Healthcare All Payer |
$2,852.30
|
|
|
EN SNARE SYSTEM 30MM
|
Facility
|
IP
|
$3,241.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$972.38 |
| Max. Negotiated Rate |
$3,111.60 |
| Rate for Payer: Aetna Commercial |
$2,495.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,528.18
|
| Rate for Payer: Cash Price |
$1,620.62
|
| Rate for Payer: Cigna Commercial |
$2,690.24
|
| Rate for Payer: First Health Commercial |
$3,079.19
|
| Rate for Payer: Humana Commercial |
$2,755.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,657.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,392.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$972.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,852.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,430.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,593.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,819.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.46
|
| Rate for Payer: PHCS Commercial |
$3,111.60
|
| Rate for Payer: United Healthcare All Payer |
$2,852.30
|
|
|
EN SNARE SYSTEM 45MM
|
Facility
|
OP
|
$3,241.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$972.38 |
| Max. Negotiated Rate |
$3,111.60 |
| Rate for Payer: Aetna Commercial |
$2,495.76
|
| Rate for Payer: Anthem Medicaid |
$1,114.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,528.18
|
| Rate for Payer: Cash Price |
$1,620.62
|
| Rate for Payer: Cigna Commercial |
$2,690.24
|
| Rate for Payer: First Health Commercial |
$3,079.19
|
| Rate for Payer: Humana Commercial |
$2,755.06
|
| Rate for Payer: Humana KY Medicaid |
$1,114.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,126.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,657.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,392.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$972.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,137.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,852.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,430.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,593.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,819.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.46
|
| Rate for Payer: PHCS Commercial |
$3,111.60
|
| Rate for Payer: United Healthcare All Payer |
$2,852.30
|
|
|
EN SNARE SYSTEM 45MM
|
Facility
|
IP
|
$3,241.25
|
|
|
Service Code
|
HCPCS C1773
|
| Hospital Charge Code |
27000250
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$972.38 |
| Max. Negotiated Rate |
$3,111.60 |
| Rate for Payer: Aetna Commercial |
$2,495.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,528.18
|
| Rate for Payer: Cash Price |
$1,620.62
|
| Rate for Payer: Cigna Commercial |
$2,690.24
|
| Rate for Payer: First Health Commercial |
$3,079.19
|
| Rate for Payer: Humana Commercial |
$2,755.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,657.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,392.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$972.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,852.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,430.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,593.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,819.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,236.46
|
| Rate for Payer: PHCS Commercial |
$3,111.60
|
| Rate for Payer: United Healthcare All Payer |
$2,852.30
|
|
|
ENSURE ENLIVE 237
|
Facility
|
OP
|
$67.15
|
|
|
Service Code
|
HCPCS B4152
|
| Hospital Charge Code |
25004537
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.14 |
| Max. Negotiated Rate |
$64.46 |
| Rate for Payer: Aetna Commercial |
$51.71
|
| Rate for Payer: Anthem Medicaid |
$23.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.38
|
| Rate for Payer: Cash Price |
$33.58
|
| Rate for Payer: Cigna Commercial |
$55.73
|
| Rate for Payer: First Health Commercial |
$63.79
|
| Rate for Payer: Humana Commercial |
$57.08
|
| Rate for Payer: Humana KY Medicaid |
$23.09
|
| Rate for Payer: Kentucky WC Medicaid |
$23.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.09
|
| Rate for Payer: Ohio Health Group HMO |
$50.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.33
|
| Rate for Payer: PHCS Commercial |
$64.46
|
| Rate for Payer: United Healthcare All Payer |
$59.09
|
|
|
ENSURE ENLIVE 237
|
Facility
|
IP
|
$67.15
|
|
|
Service Code
|
HCPCS B4152
|
| Hospital Charge Code |
25004537
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.14 |
| Max. Negotiated Rate |
$64.46 |
| Rate for Payer: Aetna Commercial |
$51.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$52.38
|
| Rate for Payer: Cash Price |
$33.58
|
| Rate for Payer: Cigna Commercial |
$55.73
|
| Rate for Payer: First Health Commercial |
$63.79
|
| Rate for Payer: Humana Commercial |
$57.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$55.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$59.09
|
| Rate for Payer: Ohio Health Group HMO |
$50.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$58.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$46.33
|
| Rate for Payer: PHCS Commercial |
$64.46
|
| Rate for Payer: United Healthcare All Payer |
$59.09
|
|
|
ENSURE LIQUID 237ML
|
Facility
|
IP
|
$66.22
|
|
|
Service Code
|
NDC 70074040711
|
| Hospital Charge Code |
25003848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.87 |
| Max. Negotiated Rate |
$63.57 |
| Rate for Payer: Aetna Commercial |
$50.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.65
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cigna Commercial |
$54.96
|
| Rate for Payer: First Health Commercial |
$62.91
|
| Rate for Payer: Humana Commercial |
$56.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.27
|
| Rate for Payer: Ohio Health Group HMO |
$49.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.69
|
| Rate for Payer: PHCS Commercial |
$63.57
|
| Rate for Payer: United Healthcare All Payer |
$58.27
|
|
|
ENSURE LIQUID 237ML
|
Facility
|
OP
|
$66.22
|
|
|
Service Code
|
NDC 70074040711
|
| Hospital Charge Code |
25003848
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.87 |
| Max. Negotiated Rate |
$63.57 |
| Rate for Payer: Aetna Commercial |
$50.99
|
| Rate for Payer: Anthem Medicaid |
$22.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.65
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cigna Commercial |
$54.96
|
| Rate for Payer: First Health Commercial |
$62.91
|
| Rate for Payer: Humana Commercial |
$56.29
|
| Rate for Payer: Humana KY Medicaid |
$22.77
|
| Rate for Payer: Kentucky WC Medicaid |
$23.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$48.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$23.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.27
|
| Rate for Payer: Ohio Health Group HMO |
$49.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$52.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.69
|
| Rate for Payer: PHCS Commercial |
$63.57
|
| Rate for Payer: United Healthcare All Payer |
$58.27
|
|
|
ENSURE PLUS 237
|
Facility
|
IP
|
$66.51
|
|
|
Service Code
|
HCPCS B4152
|
| Hospital Charge Code |
25004538
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$63.85 |
| Rate for Payer: Aetna Commercial |
$51.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$51.88
|
| Rate for Payer: Cash Price |
$33.26
|
| Rate for Payer: Cigna Commercial |
$55.20
|
| Rate for Payer: First Health Commercial |
$63.18
|
| Rate for Payer: Humana Commercial |
$56.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$54.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$49.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$19.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$58.53
|
| Rate for Payer: Ohio Health Group HMO |
$49.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$53.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$57.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$45.89
|
| Rate for Payer: PHCS Commercial |
$63.85
|
| Rate for Payer: United Healthcare All Payer |
$58.53
|
|
