|
FREEDOM ALL POLY CUP 62MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 62MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM CONSTR HD 36MM TI STD
|
Facility
|
OP
|
$11,057.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,317.18 |
| Max. Negotiated Rate |
$10,614.97 |
| Rate for Payer: Aetna Commercial |
$8,514.09
|
| Rate for Payer: Anthem Medicaid |
$3,802.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,624.66
|
| Rate for Payer: Cash Price |
$5,528.63
|
| Rate for Payer: Cigna Commercial |
$9,177.53
|
| Rate for Payer: First Health Commercial |
$10,504.40
|
| Rate for Payer: Humana Commercial |
$9,398.67
|
| Rate for Payer: Humana KY Medicaid |
$3,802.59
|
| Rate for Payer: Kentucky WC Medicaid |
$3,841.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,160.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,317.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,878.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,730.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,292.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,845.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,619.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,629.51
|
| Rate for Payer: PHCS Commercial |
$10,614.97
|
| Rate for Payer: United Healthcare All Payer |
$9,730.39
|
|
|
FREEDOM CONSTR HD 36MM TI STD
|
Facility
|
IP
|
$11,057.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,317.18 |
| Max. Negotiated Rate |
$10,614.97 |
| Rate for Payer: Aetna Commercial |
$8,514.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,624.66
|
| Rate for Payer: Cash Price |
$5,528.63
|
| Rate for Payer: Cigna Commercial |
$9,177.53
|
| Rate for Payer: First Health Commercial |
$10,504.40
|
| Rate for Payer: Humana Commercial |
$9,398.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,160.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,317.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,730.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,292.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,845.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,619.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,629.51
|
| Rate for Payer: PHCS Commercial |
$10,614.97
|
| Rate for Payer: United Healthcare All Payer |
$9,730.39
|
|
|
FREEDOM CONSTR HD 36 TI+3
|
Facility
|
OP
|
$11,057.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,317.18 |
| Max. Negotiated Rate |
$10,614.97 |
| Rate for Payer: Aetna Commercial |
$8,514.09
|
| Rate for Payer: Anthem Medicaid |
$3,802.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,624.66
|
| Rate for Payer: Cash Price |
$5,528.63
|
| Rate for Payer: Cigna Commercial |
$9,177.53
|
| Rate for Payer: First Health Commercial |
$10,504.40
|
| Rate for Payer: Humana Commercial |
$9,398.67
|
| Rate for Payer: Humana KY Medicaid |
$3,802.59
|
| Rate for Payer: Kentucky WC Medicaid |
$3,841.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,160.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,317.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,878.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,730.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,292.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,845.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,619.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,629.51
|
| Rate for Payer: PHCS Commercial |
$10,614.97
|
| Rate for Payer: United Healthcare All Payer |
$9,730.39
|
|
|
FREEDOM CONSTR HD 36 TI+3
|
Facility
|
IP
|
$11,057.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,317.18 |
| Max. Negotiated Rate |
$10,614.97 |
| Rate for Payer: Aetna Commercial |
$8,514.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,624.66
|
| Rate for Payer: Cash Price |
$5,528.63
|
| Rate for Payer: Cigna Commercial |
$9,177.53
|
| Rate for Payer: First Health Commercial |
$10,504.40
|
| Rate for Payer: Humana Commercial |
$9,398.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,160.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,317.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,730.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,292.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,845.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,619.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,629.51
|
| Rate for Payer: PHCS Commercial |
$10,614.97
|
| Rate for Payer: United Healthcare All Payer |
$9,730.39
|
|
|
FREEDOM CONSTR HD 36 TI+6
|
Facility
|
IP
|
$10,018.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,005.47 |
| Max. Negotiated Rate |
$9,617.49 |
| Rate for Payer: Aetna Commercial |
$7,714.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,814.21
|
| Rate for Payer: Cash Price |
$5,009.11
|
| Rate for Payer: Cigna Commercial |
$8,315.12
|
| Rate for Payer: First Health Commercial |
$9,517.31
|
| Rate for Payer: Humana Commercial |
$8,515.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,214.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,393.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,005.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,816.03
|
| Rate for Payer: Ohio Health Group HMO |
$7,513.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,014.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,715.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,912.57
|
| Rate for Payer: PHCS Commercial |
$9,617.49
|
| Rate for Payer: United Healthcare All Payer |
$8,816.03
|
|
|
FREEDOM CONSTR HD 36 TI+6
|
Facility
|
OP
|
$10,018.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,005.47 |
| Max. Negotiated Rate |
$9,617.49 |
| Rate for Payer: Aetna Commercial |
$7,714.03
|
| Rate for Payer: Anthem Medicaid |
$3,445.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,814.21
|
| Rate for Payer: Cash Price |
$5,009.11
|
| Rate for Payer: Cigna Commercial |
$8,315.12
|
| Rate for Payer: First Health Commercial |
$9,517.31
|
| Rate for Payer: Humana Commercial |
$8,515.49
|
| Rate for Payer: Humana KY Medicaid |
$3,445.27
|
| Rate for Payer: Kentucky WC Medicaid |
$3,480.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,214.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,393.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,005.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,514.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,816.03
|
| Rate for Payer: Ohio Health Group HMO |
$7,513.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,014.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,715.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,912.57
|
| Rate for Payer: PHCS Commercial |
$9,617.49
|
| Rate for Payer: United Healthcare All Payer |
$8,816.03
|
|
|
FREEDOM CONSTR HD 36 TI+9
|
Facility
|
OP
|
$11,057.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,317.18 |
| Max. Negotiated Rate |
$10,614.97 |
| Rate for Payer: Aetna Commercial |
$8,514.09
|
| Rate for Payer: Anthem Medicaid |
$3,802.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,624.66
|
| Rate for Payer: Cash Price |
$5,528.63
|
| Rate for Payer: Cigna Commercial |
$9,177.53
|
| Rate for Payer: First Health Commercial |
$10,504.40
|
| Rate for Payer: Humana Commercial |
$9,398.67
|
| Rate for Payer: Humana KY Medicaid |
$3,802.59
|
| Rate for Payer: Kentucky WC Medicaid |
$3,841.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,160.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,317.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,878.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,730.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,292.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,845.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,619.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,629.51
|
| Rate for Payer: PHCS Commercial |
$10,614.97
|
| Rate for Payer: United Healthcare All Payer |
$9,730.39
|
|
|
FREEDOM CONSTR HD 36 TI+9
|
Facility
|
IP
|
$11,057.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,317.18 |
| Max. Negotiated Rate |
$10,614.97 |
| Rate for Payer: Aetna Commercial |
$8,514.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,624.66
|
| Rate for Payer: Cash Price |
$5,528.63
|
| Rate for Payer: Cigna Commercial |
$9,177.53
|
| Rate for Payer: First Health Commercial |
$10,504.40
|
| Rate for Payer: Humana Commercial |
$9,398.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,066.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,160.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,317.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,730.39
|
| Rate for Payer: Ohio Health Group HMO |
$8,292.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,845.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,619.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,629.51
|
| Rate for Payer: PHCS Commercial |
$10,614.97
|
| Rate for Payer: United Healthcare All Payer |
$9,730.39
|
|
|
FREE JEJUNUM FLAP MICROVASC
|
Facility
|
OP
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
76101778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,140.50 |
| Max. Negotiated Rate |
$6,849.60 |
| Rate for Payer: Aetna Commercial |
$5,493.95
|
| Rate for Payer: Anthem Medicaid |
$2,453.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.30
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cigna Commercial |
$5,922.05
|
| Rate for Payer: First Health Commercial |
$6,778.25
|
| Rate for Payer: Humana Commercial |
$6,064.75
|
| Rate for Payer: Humana KY Medicaid |
$2,453.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,478.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,850.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,502.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,278.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,708.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,207.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,923.15
|
| Rate for Payer: PHCS Commercial |
$6,849.60
|
| Rate for Payer: United Healthcare All Payer |
$6,278.80
|
|
|
FREE JEJUNUM FLAP MICROVASC
|
Facility
|
IP
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
76101778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$2,140.50 |
| Max. Negotiated Rate |
$6,849.60 |
| Rate for Payer: Aetna Commercial |
$5,493.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.30
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cigna Commercial |
$5,922.05
|
| Rate for Payer: First Health Commercial |
$6,778.25
|
| Rate for Payer: Humana Commercial |
$6,064.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,850.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,278.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,708.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,207.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,923.15
|
| Rate for Payer: PHCS Commercial |
$6,849.60
|
| Rate for Payer: United Healthcare All Payer |
$6,278.80
|
|
|
FREE JEJUNUM FLAP MICROVASC
|
Professional
|
Both
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
76101778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$6,870.63 |
| Rate for Payer: Aetna Commercial |
$6,867.51
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,870.63
|
| Rate for Payer: Multiplan PHCS |
$4,281.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,994.50
|
| Rate for Payer: UHCCP Medicaid |
$2,497.25
|
|
|
FREE JEJUNUM FLAP MICROVASC(P
|
Professional
|
Both
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
761P1778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$6,870.63 |
| Rate for Payer: Aetna Commercial |
$6,867.51
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,870.63
|
| Rate for Payer: Multiplan PHCS |
$4,281.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,994.50
|
| Rate for Payer: UHCCP Medicaid |
$2,497.25
|
|
|
FREELINK REMOTE CONTROL KIT MR
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
FREELINK REMOTE CONTROL KIT MR
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
FREE T3
|
Facility
|
OP
|
$147.00
|
|
|
Service Code
|
HCPCS 84481
|
| Hospital Charge Code |
30000543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.94 |
| Max. Negotiated Rate |
$141.12 |
| Rate for Payer: Aetna Commercial |
$113.19
|
| Rate for Payer: Anthem Medicaid |
$16.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.04
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.94
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$122.01
|
| Rate for Payer: First Health Commercial |
$139.65
|
| Rate for Payer: Humana Commercial |
$124.95
|
| Rate for Payer: Humana KY Medicaid |
$16.94
|
| Rate for Payer: Humana Medicare Advantage |
$16.94
|
| Rate for Payer: Kentucky WC Medicaid |
$17.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.36
|
| Rate for Payer: Ohio Health Group HMO |
$110.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.43
|
| Rate for Payer: PHCS Commercial |
$141.12
|
| Rate for Payer: United Healthcare All Payer |
$129.36
|
|
|
FREE T3
|
Professional
|
Both
|
$147.00
|
|
|
Service Code
|
HCPCS 84481
|
| Hospital Charge Code |
30000543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna Commercial |
$13.01
|
| Rate for Payer: Ambetter Exchange |
$16.94
|
| Rate for Payer: Buckeye Individual/Medicaid |
$16.94
|
| Rate for Payer: Buckeye Medicare Advantage |
$16.94
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.33
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$14.86
|
| Rate for Payer: Healthspan PPO |
$17.75
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$16.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$16.94
|
| Rate for Payer: Multiplan PHCS |
$88.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$22.02
|
| Rate for Payer: UHCCP Medicaid |
$51.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$16.94
|
|
|
FREE T3
|
Facility
|
IP
|
$147.00
|
|
|
Service Code
|
HCPCS 84481
|
| Hospital Charge Code |
30000543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.10 |
| Max. Negotiated Rate |
$141.12 |
| Rate for Payer: Aetna Commercial |
$113.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$118.04
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cigna Commercial |
$122.01
|
| Rate for Payer: First Health Commercial |
$139.65
|
| Rate for Payer: Humana Commercial |
$124.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$120.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$108.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$44.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$129.36
|
| Rate for Payer: Ohio Health Group HMO |
$110.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$117.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$127.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$101.43
|
| Rate for Payer: PHCS Commercial |
$141.12
|
| Rate for Payer: United Healthcare All Payer |
$129.36
|
|
|
FREE T4
|
Facility
|
OP
|
$91.00
|
|
|
Service Code
|
HCPCS 84439
|
| Hospital Charge Code |
30000528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem Medicaid |
$9.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.02
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Humana KY Medicaid |
$9.02
|
| Rate for Payer: Humana Medicare Advantage |
$9.02
|
| Rate for Payer: Kentucky WC Medicaid |
$9.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
FREE T4
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
HCPCS 84439
|
| Hospital Charge Code |
30000528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$54.60 |
| Rate for Payer: Aetna Commercial |
$14.36
|
| Rate for Payer: Ambetter Exchange |
$9.02
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.02
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.02
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.82
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$7.90
|
| Rate for Payer: Healthspan PPO |
$9.45
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$9.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.02
|
| Rate for Payer: Multiplan PHCS |
$54.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$11.73
|
| Rate for Payer: UHCCP Medicaid |
$31.85
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.41
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.02
|
|
|
FREE T4
|
Facility
|
IP
|
$91.00
|
|
|
Service Code
|
HCPCS 84439
|
| Hospital Charge Code |
30000528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.30 |
| Max. Negotiated Rate |
$87.36 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$73.07
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: Cigna Commercial |
$75.53
|
| Rate for Payer: First Health Commercial |
$86.45
|
| Rate for Payer: Humana Commercial |
$77.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$67.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$80.08
|
| Rate for Payer: Ohio Health Group HMO |
$68.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.79
|
| Rate for Payer: PHCS Commercial |
$87.36
|
| Rate for Payer: United Healthcare All Payer |
$80.08
|
|
|
FRENECTOMY
|
Facility
|
IP
|
$3,120.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
76101658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$936.00 |
| Max. Negotiated Rate |
$2,995.20 |
| Rate for Payer: Aetna Commercial |
$2,402.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,433.60
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cigna Commercial |
$2,589.60
|
| Rate for Payer: First Health Commercial |
$2,964.00
|
| Rate for Payer: Humana Commercial |
$2,652.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,558.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,302.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$936.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,745.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,340.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,714.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,152.80
|
| Rate for Payer: PHCS Commercial |
$2,995.20
|
| Rate for Payer: United Healthcare All Payer |
$2,745.60
|
|
|
FRENECTOMY
|
Professional
|
Both
|
$3,120.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
76101658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.46 |
| Max. Negotiated Rate |
$1,872.00 |
| Rate for Payer: Aetna Commercial |
$211.29
|
| Rate for Payer: Ambetter Exchange |
$136.39
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$102.24
|
| Rate for Payer: Anthem Medicaid |
$101.46
|
| Rate for Payer: Buckeye Individual/Medicaid |
$136.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$136.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$163.67
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cigna Commercial |
$209.73
|
| Rate for Payer: Healthspan PPO |
$278.38
|
| Rate for Payer: Humana Medicaid |
$101.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.31
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$136.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$136.39
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.49
|
| Rate for Payer: Molina Healthcare Passport |
$101.46
|
| Rate for Payer: Multiplan PHCS |
$1,872.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$177.31
|
| Rate for Payer: UHCCP Medicaid |
$107.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.47
|
| Rate for Payer: Wellcare Medicare Advantage |
$136.39
|
|
|
FRENECTOMY
|
Facility
|
OP
|
$3,120.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
76101658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,072.97 |
| Max. Negotiated Rate |
$2,995.20 |
| Rate for Payer: Aetna Commercial |
$2,402.40
|
| Rate for Payer: Anthem Medicaid |
$1,072.97
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,368.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,433.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,916.14
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,847.70
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cash Price |
$1,560.00
|
| Rate for Payer: Cigna Commercial |
$2,589.60
|
| Rate for Payer: First Health Commercial |
$2,964.00
|
| Rate for Payer: Humana Commercial |
$2,652.00
|
| Rate for Payer: Humana KY Medicaid |
$1,072.97
|
| Rate for Payer: Humana Medicare Advantage |
$1,368.67
|
| Rate for Payer: Kentucky WC Medicaid |
$1,083.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,558.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,302.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,642.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,094.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,745.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,340.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,714.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,152.80
|
| Rate for Payer: PHCS Commercial |
$2,995.20
|
| Rate for Payer: United Healthcare All Payer |
$2,745.60
|
|
