|
AMPLATZ EXTRA STIFF ST. .035
|
Facility
|
IP
|
$547.52
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$525.62 |
| Rate for Payer: Aetna Commercial |
$421.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.07
|
| Rate for Payer: Cash Price |
$273.76
|
| Rate for Payer: Cigna Commercial |
$454.44
|
| Rate for Payer: First Health Commercial |
$520.14
|
| Rate for Payer: Humana Commercial |
$465.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$448.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$481.82
|
| Rate for Payer: Ohio Health Group HMO |
$410.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.73
|
| Rate for Payer: PHCS Commercial |
$525.62
|
| Rate for Payer: United Healthcare All Payer |
$481.82
|
|
|
AMPLATZ EXTRA STIFF ST. .035
|
Facility
|
OP
|
$547.52
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$71.18 |
| Max. Negotiated Rate |
$525.62 |
| Rate for Payer: Aetna Commercial |
$421.59
|
| Rate for Payer: Anthem Medicaid |
$188.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$427.07
|
| Rate for Payer: Cash Price |
$273.76
|
| Rate for Payer: Cigna Commercial |
$454.44
|
| Rate for Payer: First Health Commercial |
$520.14
|
| Rate for Payer: Humana Commercial |
$465.39
|
| Rate for Payer: Humana KY Medicaid |
$188.29
|
| Rate for Payer: Kentucky WC Medicaid |
$190.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$448.97
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$404.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$164.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$192.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$481.82
|
| Rate for Payer: Ohio Health Group HMO |
$410.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$109.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$71.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$169.73
|
| Rate for Payer: PHCS Commercial |
$525.62
|
| Rate for Payer: United Healthcare All Payer |
$481.82
|
|
|
AMPLATZ RENAL DILATOR/SHEATH S
|
Facility
|
OP
|
$3,138.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$407.94 |
| Max. Negotiated Rate |
$3,012.48 |
| Rate for Payer: Aetna Commercial |
$2,416.26
|
| Rate for Payer: Anthem Medicaid |
$1,079.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,447.64
|
| Rate for Payer: Cash Price |
$1,569.00
|
| Rate for Payer: Cigna Commercial |
$2,604.54
|
| Rate for Payer: First Health Commercial |
$2,981.10
|
| Rate for Payer: Humana Commercial |
$2,667.30
|
| Rate for Payer: Humana KY Medicaid |
$1,079.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,090.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,573.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,315.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$941.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,100.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,761.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,353.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$627.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$407.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$972.78
|
| Rate for Payer: PHCS Commercial |
$3,012.48
|
| Rate for Payer: United Healthcare All Payer |
$2,761.44
|
|
|
AMPLATZ RENAL DILATOR/SHEATH S
|
Facility
|
IP
|
$3,138.00
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$407.94 |
| Max. Negotiated Rate |
$3,012.48 |
| Rate for Payer: Aetna Commercial |
$2,416.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,447.64
|
| Rate for Payer: Cash Price |
$1,569.00
|
| Rate for Payer: Cigna Commercial |
$2,604.54
|
| Rate for Payer: First Health Commercial |
$2,981.10
|
| Rate for Payer: Humana Commercial |
$2,667.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,573.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,315.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$941.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,761.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,353.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$627.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$407.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$972.78
|
| Rate for Payer: PHCS Commercial |
$3,012.48
|
| Rate for Payer: United Healthcare All Payer |
$2,761.44
|
|
|
AMPLATZ SS .035*260
|
Facility
|
IP
|
$802.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
AMPLATZ SS .035*260
|
Facility
|
OP
|
$802.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$104.32 |
| Max. Negotiated Rate |
$770.40 |
| Rate for Payer: Aetna Commercial |
$617.92
|
| Rate for Payer: Anthem Medicaid |
$275.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$625.95
|
| Rate for Payer: Cash Price |
$401.25
|
| Rate for Payer: Cigna Commercial |
$666.08
|
| Rate for Payer: First Health Commercial |
$762.38
|
| Rate for Payer: Humana Commercial |
$682.12
|
| Rate for Payer: Humana KY Medicaid |
$275.98
|
| Rate for Payer: Kentucky WC Medicaid |
$278.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$658.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$592.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$281.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$706.20
|
| Rate for Payer: Ohio Health Group HMO |
$601.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$160.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$248.78
|
| Rate for Payer: PHCS Commercial |
$770.40
|
| Rate for Payer: United Healthcare All Payer |
$706.20
|
|
|
AMPLATZ SS .035*6*180
|
Facility
|
IP
|
$782.66
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.75 |
| Max. Negotiated Rate |
$751.35 |
| Rate for Payer: Aetna Commercial |
$602.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$610.47
|
| Rate for Payer: Cash Price |
$391.33
|
| Rate for Payer: Cigna Commercial |
$649.61
|
| Rate for Payer: First Health Commercial |
$743.53
|
| Rate for Payer: Humana Commercial |
$665.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$641.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$577.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$688.74
|
| Rate for Payer: Ohio Health Group HMO |
$587.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.62
|
| Rate for Payer: PHCS Commercial |
$751.35
|
| Rate for Payer: United Healthcare All Payer |
$688.74
|
|
|
AMPLATZ SS .035*6*180
|
Facility
|
OP
|
$782.66
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$101.75 |
| Max. Negotiated Rate |
$751.35 |
| Rate for Payer: Aetna Commercial |
$602.65
|
| Rate for Payer: Anthem Medicaid |
$269.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$610.47
|
| Rate for Payer: Cash Price |
$391.33
|
| Rate for Payer: Cigna Commercial |
$649.61
|
| Rate for Payer: First Health Commercial |
$743.53
|
| Rate for Payer: Humana Commercial |
$665.26
|
| Rate for Payer: Humana KY Medicaid |
$269.16
|
| Rate for Payer: Kentucky WC Medicaid |
$271.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$641.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$577.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$234.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$274.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$688.74
|
| Rate for Payer: Ohio Health Group HMO |
$587.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$156.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$101.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$242.62
|
| Rate for Payer: PHCS Commercial |
$751.35
|
| Rate for Payer: United Healthcare All Payer |
$688.74
|
|
|
AMPLATZ SS 145CM
|
Facility
|
IP
|
$523.08
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$502.16 |
| Rate for Payer: Aetna Commercial |
$402.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$408.00
|
| Rate for Payer: Cash Price |
$261.54
|
| Rate for Payer: Cigna Commercial |
$434.16
|
| Rate for Payer: First Health Commercial |
$496.93
|
| Rate for Payer: Humana Commercial |
$444.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$428.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$386.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$460.31
|
| Rate for Payer: Ohio Health Group HMO |
$392.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$502.16
|
| Rate for Payer: United Healthcare All Payer |
$460.31
|
|
|
AMPLATZ SS 145CM
|
Facility
|
OP
|
$523.08
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$502.16 |
| Rate for Payer: Aetna Commercial |
$402.77
|
| Rate for Payer: Anthem Medicaid |
$179.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$408.00
|
| Rate for Payer: Cash Price |
$261.54
|
| Rate for Payer: Cigna Commercial |
$434.16
|
| Rate for Payer: First Health Commercial |
$496.93
|
| Rate for Payer: Humana Commercial |
$444.62
|
| Rate for Payer: Humana KY Medicaid |
$179.89
|
| Rate for Payer: Kentucky WC Medicaid |
$181.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$428.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$386.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$183.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$460.31
|
| Rate for Payer: Ohio Health Group HMO |
$392.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$104.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$502.16
|
| Rate for Payer: United Healthcare All Payer |
$460.31
|
|
|
AMPLATZ STRAIGHT 0.35 75CM
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.42 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem Medicaid |
$183.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Humana KY Medicaid |
$183.64
|
| Rate for Payer: Kentucky WC Medicaid |
$185.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.54
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
AMPLATZ STRAIGHT 0.35 75CM
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$69.42 |
| Max. Negotiated Rate |
$512.64 |
| Rate for Payer: Aetna Commercial |
$411.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.52
|
| Rate for Payer: Cash Price |
$267.00
|
| Rate for Payer: Cigna Commercial |
$443.22
|
| Rate for Payer: First Health Commercial |
$507.30
|
| Rate for Payer: Humana Commercial |
$453.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$394.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.92
|
| Rate for Payer: Ohio Health Group HMO |
$400.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.54
|
| Rate for Payer: PHCS Commercial |
$512.64
|
| Rate for Payer: United Healthcare All Payer |
$469.92
|
|
|
AMPLATZ WIRE PTFE .035 STR
|
Facility
|
IP
|
$527.14
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.53 |
| Max. Negotiated Rate |
$506.05 |
| Rate for Payer: Aetna Commercial |
$405.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.17
|
| Rate for Payer: Cash Price |
$263.57
|
| Rate for Payer: Cigna Commercial |
$437.53
|
| Rate for Payer: First Health Commercial |
$500.78
|
| Rate for Payer: Humana Commercial |
$448.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$463.88
|
| Rate for Payer: Ohio Health Group HMO |
$395.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.41
|
| Rate for Payer: PHCS Commercial |
$506.05
|
| Rate for Payer: United Healthcare All Payer |
$463.88
|
|
|
AMPLATZ WIRE PTFE .035 STR
|
Facility
|
OP
|
$527.14
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$68.53 |
| Max. Negotiated Rate |
$506.05 |
| Rate for Payer: Aetna Commercial |
$405.90
|
| Rate for Payer: Anthem Medicaid |
$181.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$411.17
|
| Rate for Payer: Cash Price |
$263.57
|
| Rate for Payer: Cigna Commercial |
$437.53
|
| Rate for Payer: First Health Commercial |
$500.78
|
| Rate for Payer: Humana Commercial |
$448.07
|
| Rate for Payer: Humana KY Medicaid |
$181.28
|
| Rate for Payer: Kentucky WC Medicaid |
$183.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$432.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$389.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$158.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$184.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$463.88
|
| Rate for Payer: Ohio Health Group HMO |
$395.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$105.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$68.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$163.41
|
| Rate for Payer: PHCS Commercial |
$506.05
|
| Rate for Payer: United Healthcare All Payer |
$463.88
|
|
|
AMPUL LANOXIN (DIGOXI .5MG/2ML
|
Facility
|
OP
|
$112.50
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
25002020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.62 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$86.62
|
| Rate for Payer: Anthem Medicaid |
$38.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.75
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Cigna Commercial |
$93.38
|
| Rate for Payer: First Health Commercial |
$106.88
|
| Rate for Payer: Humana Commercial |
$95.62
|
| Rate for Payer: Humana KY Medicaid |
$38.69
|
| Rate for Payer: Kentucky WC Medicaid |
$39.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.00
|
| Rate for Payer: Ohio Health Group HMO |
$84.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.88
|
| Rate for Payer: PHCS Commercial |
$108.00
|
| Rate for Payer: United Healthcare All Payer |
$99.00
|
|
|
AMPUL LANOXIN (DIGOXI .5MG/2ML
|
Facility
|
IP
|
$112.50
|
|
|
Service Code
|
HCPCS J1160
|
| Hospital Charge Code |
25002020
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.62 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna Commercial |
$86.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.75
|
| Rate for Payer: Cash Price |
$56.25
|
| Rate for Payer: Cigna Commercial |
$93.38
|
| Rate for Payer: First Health Commercial |
$106.88
|
| Rate for Payer: Humana Commercial |
$95.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.00
|
| Rate for Payer: Ohio Health Group HMO |
$84.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.88
|
| Rate for Payer: PHCS Commercial |
$108.00
|
| Rate for Payer: United Healthcare All Payer |
$99.00
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
IP
|
$890.00
|
|
|
Service Code
|
HCPCS 27592
|
| Hospital Charge Code |
76100880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$115.70 |
| Max. Negotiated Rate |
$854.40 |
| Rate for Payer: Aetna Commercial |
$685.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$694.20
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cigna Commercial |
$738.70
|
| Rate for Payer: First Health Commercial |
$845.50
|
| Rate for Payer: Humana Commercial |
$756.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$729.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$656.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$783.20
|
| Rate for Payer: Ohio Health Group HMO |
$667.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$178.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$115.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$275.90
|
| Rate for Payer: PHCS Commercial |
$854.40
|
| Rate for Payer: United Healthcare All Payer |
$783.20
|
|
|
AMPUTATE LEG AT THIGH
|
Facility
|
OP
|
$890.00
|
|
|
Service Code
|
HCPCS 27592
|
| Hospital Charge Code |
76100880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$115.70 |
| Max. Negotiated Rate |
$854.40 |
| Rate for Payer: Aetna Commercial |
$685.30
|
| Rate for Payer: Anthem Medicaid |
$306.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$694.20
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cigna Commercial |
$738.70
|
| Rate for Payer: First Health Commercial |
$845.50
|
| Rate for Payer: Humana Commercial |
$756.50
|
| Rate for Payer: Humana KY Medicaid |
$306.07
|
| Rate for Payer: Kentucky WC Medicaid |
$309.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$729.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$656.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$267.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$312.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$783.20
|
| Rate for Payer: Ohio Health Group HMO |
$667.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$178.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$115.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$275.90
|
| Rate for Payer: PHCS Commercial |
$854.40
|
| Rate for Payer: United Healthcare All Payer |
$783.20
|
|
|
AMPUTATE LEG AT THIGH
|
Professional
|
Both
|
$890.00
|
|
|
Service Code
|
HCPCS 27592
|
| Hospital Charge Code |
76100880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$311.50 |
| Max. Negotiated Rate |
$1,118.96 |
| Rate for Payer: Aetna Commercial |
$1,043.25
|
| Rate for Payer: Anthem Medicaid |
$513.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$890.00
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cigna Commercial |
$1,118.96
|
| Rate for Payer: Healthspan PPO |
$944.96
|
| Rate for Payer: Humana Medicaid |
$513.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$892.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$523.67
|
| Rate for Payer: Molina Healthcare Passport |
$513.40
|
| Rate for Payer: Multiplan PHCS |
$534.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$623.00
|
| Rate for Payer: UHCCP Medicaid |
$311.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$518.53
|
|
|
AMPUTATE LEG AT THIGH(P
|
Professional
|
Both
|
$890.00
|
|
|
Service Code
|
HCPCS 27592
|
| Hospital Charge Code |
761P0880
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$311.50 |
| Max. Negotiated Rate |
$1,118.96 |
| Rate for Payer: Aetna Commercial |
$1,043.25
|
| Rate for Payer: Anthem Medicaid |
$513.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$890.00
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cash Price |
$445.00
|
| Rate for Payer: Cigna Commercial |
$1,118.96
|
| Rate for Payer: Healthspan PPO |
$944.96
|
| Rate for Payer: Humana Medicaid |
$513.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$892.36
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$523.67
|
| Rate for Payer: Molina Healthcare Passport |
$513.40
|
| Rate for Payer: Multiplan PHCS |
$534.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$623.00
|
| Rate for Payer: UHCCP Medicaid |
$311.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$518.53
|
|
|
AMPUTATE METACARPAL BONE
|
Facility
|
IP
|
$905.00
|
|
|
Service Code
|
HCPCS 26910
|
| Hospital Charge Code |
76100755
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.65 |
| Max. Negotiated Rate |
$868.80 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.90
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$751.15
|
| Rate for Payer: First Health Commercial |
$859.75
|
| Rate for Payer: Humana Commercial |
$769.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$271.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.40
|
| Rate for Payer: Ohio Health Group HMO |
$678.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.55
|
| Rate for Payer: PHCS Commercial |
$868.80
|
| Rate for Payer: United Healthcare All Payer |
$796.40
|
|
|
AMPUTATE METACARPAL BONE
|
Professional
|
Both
|
$905.00
|
|
|
Service Code
|
HCPCS 26910
|
| Hospital Charge Code |
76100755
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$316.75 |
| Max. Negotiated Rate |
$1,189.35 |
| Rate for Payer: Aetna Commercial |
$1,010.24
|
| Rate for Payer: Anthem Medicaid |
$371.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$905.00
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$1,189.35
|
| Rate for Payer: Healthspan PPO |
$915.07
|
| Rate for Payer: Humana Medicaid |
$371.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$869.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$379.12
|
| Rate for Payer: Molina Healthcare Passport |
$371.69
|
| Rate for Payer: Multiplan PHCS |
$543.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$633.50
|
| Rate for Payer: UHCCP Medicaid |
$316.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$375.41
|
|
|
AMPUTATE METACARPAL BONE
|
Facility
|
OP
|
$905.00
|
|
|
Service Code
|
HCPCS 26910
|
| Hospital Charge Code |
76100755
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$117.65 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$696.85
|
| Rate for Payer: Anthem Medicaid |
$311.23
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$705.90
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$751.15
|
| Rate for Payer: First Health Commercial |
$859.75
|
| Rate for Payer: Humana Commercial |
$769.25
|
| Rate for Payer: Humana KY Medicaid |
$311.23
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$314.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$742.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$667.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$317.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$796.40
|
| Rate for Payer: Ohio Health Group HMO |
$678.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$181.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$117.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$280.55
|
| Rate for Payer: PHCS Commercial |
$868.80
|
| Rate for Payer: United Healthcare All Payer |
$796.40
|
|
|
AMPUTATE METACARPAL BONE(P
|
Professional
|
Both
|
$905.00
|
|
|
Service Code
|
HCPCS 26910
|
| Hospital Charge Code |
761P0755
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$316.75 |
| Max. Negotiated Rate |
$1,189.35 |
| Rate for Payer: Aetna Commercial |
$1,010.24
|
| Rate for Payer: Anthem Medicaid |
$371.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$905.00
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cash Price |
$452.50
|
| Rate for Payer: Cigna Commercial |
$1,189.35
|
| Rate for Payer: Healthspan PPO |
$915.07
|
| Rate for Payer: Humana Medicaid |
$371.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$869.77
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$379.12
|
| Rate for Payer: Molina Healthcare Passport |
$371.69
|
| Rate for Payer: Multiplan PHCS |
$543.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$633.50
|
| Rate for Payer: UHCCP Medicaid |
$316.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$375.41
|
|
|
AMPUTAT FNGTHMBPRISECJNTPHLN(P
|
Professional
|
Both
|
$1,475.00
|
|
|
Service Code
|
HCPCS 26951
|
| Hospital Charge Code |
761P0756
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$218.29 |
| Max. Negotiated Rate |
$1,475.00 |
| Rate for Payer: Aetna Commercial |
$859.78
|
| Rate for Payer: Anthem Medicaid |
$218.29
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,475.00
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cash Price |
$737.50
|
| Rate for Payer: Cigna Commercial |
$1,001.82
|
| Rate for Payer: Healthspan PPO |
$778.78
|
| Rate for Payer: Humana Medicaid |
$218.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$772.30
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$222.66
|
| Rate for Payer: Molina Healthcare Passport |
$218.29
|
| Rate for Payer: Multiplan PHCS |
$885.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,032.50
|
| Rate for Payer: UHCCP Medicaid |
$516.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$220.47
|
|
