|
39 +2.5 INF/24 TI GLENOSPHERE
|
Facility
|
OP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem Medicaid |
$4,737.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Humana KY Medicaid |
$4,737.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,785.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,832.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39 +2.5 INF/28 TI GLENOSPHERE
|
Facility
|
OP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem Medicaid |
$4,737.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Humana KY Medicaid |
$4,737.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,785.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,832.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39 +2.5 INF/28 TI GLENOSPHERE
|
Facility
|
IP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39/28 TI GLENOSPHERE
|
Facility
|
IP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39/28 TI GLENOSPHERE
|
Facility
|
OP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem Medicaid |
$4,737.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Humana KY Medicaid |
$4,737.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,785.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,832.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39 +4 LAT/24 TI GLENOSPHERE
|
Facility
|
OP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem Medicaid |
$4,737.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Humana KY Medicaid |
$4,737.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,785.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,832.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39 +4 LAT/24 TI GLENOSPHERE
|
Facility
|
IP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39 +4 LAT/28 TI GLENOSPHERE
|
Facility
|
IP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
39 +4 LAT/28 TI GLENOSPHERE
|
Facility
|
OP
|
$13,776.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,132.80 |
| Max. Negotiated Rate |
$13,224.96 |
| Rate for Payer: Aetna Commercial |
$10,607.52
|
| Rate for Payer: Anthem Medicaid |
$4,737.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,745.28
|
| Rate for Payer: Cash Price |
$6,888.00
|
| Rate for Payer: Cigna Commercial |
$11,434.08
|
| Rate for Payer: First Health Commercial |
$13,087.20
|
| Rate for Payer: Humana Commercial |
$11,709.60
|
| Rate for Payer: Humana KY Medicaid |
$4,737.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,785.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,296.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,166.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,132.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,832.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,122.88
|
| Rate for Payer: Ohio Health Group HMO |
$10,332.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,985.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,505.44
|
| Rate for Payer: PHCS Commercial |
$13,224.96
|
| Rate for Payer: United Healthcare All Payer |
$12,122.88
|
|
|
3DRC CATH 5F
|
Facility
|
IP
|
$440.26
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$422.65 |
| Rate for Payer: Aetna Commercial |
$339.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.40
|
| Rate for Payer: Cash Price |
$220.13
|
| Rate for Payer: Cigna Commercial |
$365.42
|
| Rate for Payer: First Health Commercial |
$418.25
|
| Rate for Payer: Humana Commercial |
$374.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$361.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.43
|
| Rate for Payer: Ohio Health Group HMO |
$330.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.78
|
| Rate for Payer: PHCS Commercial |
$422.65
|
| Rate for Payer: United Healthcare All Payer |
$387.43
|
|
|
3DRC CATH 5F
|
Facility
|
OP
|
$440.26
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.08 |
| Max. Negotiated Rate |
$422.65 |
| Rate for Payer: Aetna Commercial |
$339.00
|
| Rate for Payer: Anthem Medicaid |
$151.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$343.40
|
| Rate for Payer: Cash Price |
$220.13
|
| Rate for Payer: Cigna Commercial |
$365.42
|
| Rate for Payer: First Health Commercial |
$418.25
|
| Rate for Payer: Humana Commercial |
$374.22
|
| Rate for Payer: Humana KY Medicaid |
$151.41
|
| Rate for Payer: Kentucky WC Medicaid |
$152.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$361.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$324.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$154.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$387.43
|
| Rate for Payer: Ohio Health Group HMO |
$330.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$383.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$303.78
|
| Rate for Payer: PHCS Commercial |
$422.65
|
| Rate for Payer: United Healthcare All Payer |
$387.43
|
|
|
3DRC CATH 6F 100CM
|
Facility
|
IP
|
$168.75
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna Commercial |
$129.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.62
|
| Rate for Payer: Cash Price |
$84.38
|
| Rate for Payer: Cigna Commercial |
$140.06
|
| Rate for Payer: First Health Commercial |
$160.31
|
| Rate for Payer: Humana Commercial |
$143.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.50
|
| Rate for Payer: Ohio Health Group HMO |
$126.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.44
|
| Rate for Payer: PHCS Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Payer |
$148.50
|
|
|
3DRC CATH 6F 100CM
|
Facility
|
OP
|
$168.75
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$162.00 |
| Rate for Payer: Aetna Commercial |
$129.94
|
| Rate for Payer: Anthem Medicaid |
$58.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.62
|
| Rate for Payer: Cash Price |
$84.38
|
| Rate for Payer: Cigna Commercial |
$140.06
|
| Rate for Payer: First Health Commercial |
$160.31
|
| Rate for Payer: Humana Commercial |
$143.44
|
| Rate for Payer: Humana KY Medicaid |
$58.03
|
| Rate for Payer: Kentucky WC Medicaid |
$58.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$138.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$59.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$148.50
|
| Rate for Payer: Ohio Health Group HMO |
$126.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$135.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$116.44
|
| Rate for Payer: PHCS Commercial |
$162.00
|
| Rate for Payer: United Healthcare All Payer |
$148.50
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
IP
|
$927.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
35000095
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$278.10 |
| Max. Negotiated Rate |
$889.92 |
| Rate for Payer: Aetna Commercial |
$713.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$723.06
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cigna Commercial |
$769.41
|
| Rate for Payer: First Health Commercial |
$880.65
|
| Rate for Payer: Humana Commercial |
$787.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$760.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$684.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$815.76
|
| Rate for Payer: Ohio Health Group HMO |
$695.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$806.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$639.63
|
| Rate for Payer: PHCS Commercial |
$889.92
|
| Rate for Payer: United Healthcare All Payer |
$815.76
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Facility
|
OP
|
$927.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
35000095
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$278.10 |
| Max. Negotiated Rate |
$889.92 |
| Rate for Payer: Aetna Commercial |
$713.79
|
| Rate for Payer: Anthem Medicaid |
$318.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$723.06
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cigna Commercial |
$769.41
|
| Rate for Payer: First Health Commercial |
$880.65
|
| Rate for Payer: Humana Commercial |
$787.95
|
| Rate for Payer: Humana KY Medicaid |
$318.80
|
| Rate for Payer: Kentucky WC Medicaid |
$322.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$760.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$684.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$278.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$325.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$815.76
|
| Rate for Payer: Ohio Health Group HMO |
$695.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$806.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$639.63
|
| Rate for Payer: PHCS Commercial |
$889.92
|
| Rate for Payer: United Healthcare All Payer |
$815.76
|
|
|
3D RENDER W/INTRP POSTPROCES
|
Professional
|
Both
|
$927.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
35000095
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$556.20 |
| Rate for Payer: Aetna Commercial |
$121.42
|
| Rate for Payer: Ambetter Exchange |
$23.34
|
| Rate for Payer: Anthem Medicaid |
$97.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.01
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cash Price |
$463.50
|
| Rate for Payer: Cigna Commercial |
$178.97
|
| Rate for Payer: Healthspan PPO |
$83.44
|
| Rate for Payer: Humana Medicaid |
$97.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.79
|
| Rate for Payer: Molina Healthcare Passport |
$97.83
|
| Rate for Payer: Multiplan PHCS |
$556.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.34
|
| Rate for Payer: UHCCP Medicaid |
$324.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.34
|
|
|
3D RENDER W/INTRP POSTPROCES(P
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
350P0095
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$178.97 |
| Rate for Payer: Aetna Commercial |
$121.42
|
| Rate for Payer: Ambetter Exchange |
$23.34
|
| Rate for Payer: Anthem Medicaid |
$97.83
|
| Rate for Payer: Buckeye Individual/Medicaid |
$23.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$23.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$28.01
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cigna Commercial |
$178.97
|
| Rate for Payer: Healthspan PPO |
$83.44
|
| Rate for Payer: Humana Medicaid |
$97.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$12.95
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$23.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$99.79
|
| Rate for Payer: Molina Healthcare Passport |
$97.83
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$30.34
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$98.81
|
| Rate for Payer: Wellcare Medicare Advantage |
$23.34
|
|
|
3D RENDER W/INTRP POSTPROCES(T
|
Facility
|
OP
|
$887.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
350T0095
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$266.10 |
| Max. Negotiated Rate |
$851.52 |
| Rate for Payer: Aetna Commercial |
$682.99
|
| Rate for Payer: Anthem Medicaid |
$305.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.86
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$736.21
|
| Rate for Payer: First Health Commercial |
$842.65
|
| Rate for Payer: Humana Commercial |
$753.95
|
| Rate for Payer: Humana KY Medicaid |
$305.04
|
| Rate for Payer: Kentucky WC Medicaid |
$308.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$727.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$311.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$780.56
|
| Rate for Payer: Ohio Health Group HMO |
$665.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.03
|
| Rate for Payer: PHCS Commercial |
$851.52
|
| Rate for Payer: United Healthcare All Payer |
$780.56
|
|
|
3D RENDER W/INTRP POSTPROCES(T
|
Facility
|
IP
|
$887.00
|
|
|
Service Code
|
HCPCS 76376
|
| Hospital Charge Code |
350T0095
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$266.10 |
| Max. Negotiated Rate |
$851.52 |
| Rate for Payer: Aetna Commercial |
$682.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$691.86
|
| Rate for Payer: Cash Price |
$443.50
|
| Rate for Payer: Cigna Commercial |
$736.21
|
| Rate for Payer: First Health Commercial |
$842.65
|
| Rate for Payer: Humana Commercial |
$753.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$727.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$654.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$266.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$780.56
|
| Rate for Payer: Ohio Health Group HMO |
$665.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$709.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$771.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$612.03
|
| Rate for Payer: PHCS Commercial |
$851.52
|
| Rate for Payer: United Healthcare All Payer |
$780.56
|
|
|
3D REND W/INTERP REP OF CT
|
Facility
|
IP
|
$1,109.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
40000005
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$332.70 |
| Max. Negotiated Rate |
$1,064.64 |
| Rate for Payer: Aetna Commercial |
$853.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$865.02
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cigna Commercial |
$920.47
|
| Rate for Payer: First Health Commercial |
$1,053.55
|
| Rate for Payer: Humana Commercial |
$942.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$909.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$818.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$975.92
|
| Rate for Payer: Ohio Health Group HMO |
$831.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$887.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$964.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$765.21
|
| Rate for Payer: PHCS Commercial |
$1,064.64
|
| Rate for Payer: United Healthcare All Payer |
$975.92
|
|
|
3D REND W/INTERP REP OF CT
|
Facility
|
OP
|
$1,109.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
40000004
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$332.70 |
| Max. Negotiated Rate |
$1,064.64 |
| Rate for Payer: Aetna Commercial |
$853.93
|
| Rate for Payer: Anthem Medicaid |
$381.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$865.02
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cigna Commercial |
$920.47
|
| Rate for Payer: First Health Commercial |
$1,053.55
|
| Rate for Payer: Humana Commercial |
$942.65
|
| Rate for Payer: Humana KY Medicaid |
$381.39
|
| Rate for Payer: Kentucky WC Medicaid |
$385.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$909.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$818.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$389.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$975.92
|
| Rate for Payer: Ohio Health Group HMO |
$831.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$887.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$964.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$765.21
|
| Rate for Payer: PHCS Commercial |
$1,064.64
|
| Rate for Payer: United Healthcare All Payer |
$975.92
|
|
|
3D REND W/INTERP REP OF CT
|
Facility
|
IP
|
$1,109.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
40000004
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$332.70 |
| Max. Negotiated Rate |
$1,064.64 |
| Rate for Payer: Aetna Commercial |
$853.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$865.02
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cigna Commercial |
$920.47
|
| Rate for Payer: First Health Commercial |
$1,053.55
|
| Rate for Payer: Humana Commercial |
$942.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$909.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$818.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$975.92
|
| Rate for Payer: Ohio Health Group HMO |
$831.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$887.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$964.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$765.21
|
| Rate for Payer: PHCS Commercial |
$1,064.64
|
| Rate for Payer: United Healthcare All Payer |
$975.92
|
|
|
3D REND W/INTERP REP OF CT
|
Professional
|
Both
|
$1,109.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
40000005
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$50.14 |
| Max. Negotiated Rate |
$665.40 |
| Rate for Payer: Aetna Commercial |
$179.32
|
| Rate for Payer: Ambetter Exchange |
$72.64
|
| Rate for Payer: Anthem Medicaid |
$127.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$72.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.17
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cigna Commercial |
$234.40
|
| Rate for Payer: Healthspan PPO |
$123.22
|
| Rate for Payer: Humana Medicaid |
$127.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$50.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$72.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.51
|
| Rate for Payer: Molina Healthcare Passport |
$127.95
|
| Rate for Payer: Multiplan PHCS |
$665.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.43
|
| Rate for Payer: UHCCP Medicaid |
$388.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$72.64
|
|
|
3D REND W/INTERP REP OF CT
|
Professional
|
Both
|
$1,109.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
40000004
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$50.14 |
| Max. Negotiated Rate |
$665.40 |
| Rate for Payer: Aetna Commercial |
$179.32
|
| Rate for Payer: Ambetter Exchange |
$72.64
|
| Rate for Payer: Anthem Medicaid |
$127.95
|
| Rate for Payer: Buckeye Individual/Medicaid |
$72.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$72.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$87.17
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cigna Commercial |
$234.40
|
| Rate for Payer: Healthspan PPO |
$123.22
|
| Rate for Payer: Humana Medicaid |
$127.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$50.14
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$72.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$72.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$130.51
|
| Rate for Payer: Molina Healthcare Passport |
$127.95
|
| Rate for Payer: Multiplan PHCS |
$665.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$94.43
|
| Rate for Payer: UHCCP Medicaid |
$388.15
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$129.23
|
| Rate for Payer: Wellcare Medicare Advantage |
$72.64
|
|
|
3D REND W/INTERP REP OF CT
|
Facility
|
OP
|
$1,109.00
|
|
|
Service Code
|
HCPCS 76377
|
| Hospital Charge Code |
40000005
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$332.70 |
| Max. Negotiated Rate |
$1,064.64 |
| Rate for Payer: Aetna Commercial |
$853.93
|
| Rate for Payer: Anthem Medicaid |
$381.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$865.02
|
| Rate for Payer: Cash Price |
$554.50
|
| Rate for Payer: Cigna Commercial |
$920.47
|
| Rate for Payer: First Health Commercial |
$1,053.55
|
| Rate for Payer: Humana Commercial |
$942.65
|
| Rate for Payer: Humana KY Medicaid |
$381.39
|
| Rate for Payer: Kentucky WC Medicaid |
$385.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$909.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$818.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$389.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$975.92
|
| Rate for Payer: Ohio Health Group HMO |
$831.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$887.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$964.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$765.21
|
| Rate for Payer: PHCS Commercial |
$1,064.64
|
| Rate for Payer: United Healthcare All Payer |
$975.92
|
|
