|
HEAD ENDO II MOD SZ 53
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 54
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 54
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 55
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 55
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 56
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 56
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 57
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 57
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 58
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 58
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 59
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 59
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 60
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 60
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 61
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD ENDO II MOD SZ 61
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
HEAD FEM BIOLOX DELTA 36MM +
|
Facility
|
IP
|
$19,415.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.06 |
| Max. Negotiated Rate |
$18,639.24 |
| Rate for Payer: Aetna Commercial |
$14,950.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,144.39
|
| Rate for Payer: Cash Price |
$9,707.94
|
| Rate for Payer: Cigna Commercial |
$16,115.18
|
| Rate for Payer: First Health Commercial |
$18,445.09
|
| Rate for Payer: Humana Commercial |
$16,503.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,921.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,328.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,824.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,085.97
|
| Rate for Payer: Ohio Health Group HMO |
$14,561.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,883.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,524.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,018.92
|
| Rate for Payer: PHCS Commercial |
$18,639.24
|
| Rate for Payer: United Healthcare All Payer |
$17,085.97
|
|
|
HEAD FEM BIOLOX DELTA 36MM +
|
Facility
|
OP
|
$19,415.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.06 |
| Max. Negotiated Rate |
$18,639.24 |
| Rate for Payer: Aetna Commercial |
$14,950.23
|
| Rate for Payer: Anthem Medicaid |
$6,677.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,144.39
|
| Rate for Payer: Cash Price |
$9,707.94
|
| Rate for Payer: Cigna Commercial |
$16,115.18
|
| Rate for Payer: First Health Commercial |
$18,445.09
|
| Rate for Payer: Humana Commercial |
$16,503.50
|
| Rate for Payer: Humana KY Medicaid |
$6,677.12
|
| Rate for Payer: Kentucky WC Medicaid |
$6,745.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,921.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,328.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,824.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,811.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,085.97
|
| Rate for Payer: Ohio Health Group HMO |
$14,561.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,883.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,524.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,018.92
|
| Rate for Payer: PHCS Commercial |
$18,639.24
|
| Rate for Payer: United Healthcare All Payer |
$17,085.97
|
|
|
HEAD FEM BIOX DELTA ART 32MM +
|
Facility
|
IP
|
$10,905.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.76 |
| Max. Negotiated Rate |
$10,469.64 |
| Rate for Payer: Aetna Commercial |
$8,397.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,506.58
|
| Rate for Payer: Cash Price |
$5,452.94
|
| Rate for Payer: Cigna Commercial |
$9,051.87
|
| Rate for Payer: First Health Commercial |
$10,360.58
|
| Rate for Payer: Humana Commercial |
$9,269.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,942.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,048.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,271.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,597.17
|
| Rate for Payer: Ohio Health Group HMO |
$8,179.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,181.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,380.82
|
| Rate for Payer: PHCS Commercial |
$10,469.64
|
| Rate for Payer: United Healthcare All Payer |
$9,597.17
|
|
|
HEAD FEM BIOX DELTA ART 32MM +
|
Facility
|
OP
|
$10,905.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.76 |
| Max. Negotiated Rate |
$10,469.64 |
| Rate for Payer: Aetna Commercial |
$8,397.52
|
| Rate for Payer: Anthem Medicaid |
$3,750.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,506.58
|
| Rate for Payer: Cash Price |
$5,452.94
|
| Rate for Payer: Cigna Commercial |
$9,051.87
|
| Rate for Payer: First Health Commercial |
$10,360.58
|
| Rate for Payer: Humana Commercial |
$9,269.99
|
| Rate for Payer: Humana KY Medicaid |
$3,750.53
|
| Rate for Payer: Kentucky WC Medicaid |
$3,788.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,942.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,048.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,271.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,825.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,597.17
|
| Rate for Payer: Ohio Health Group HMO |
$8,179.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,181.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,380.82
|
| Rate for Payer: PHCS Commercial |
$10,469.64
|
| Rate for Payer: United Healthcare All Payer |
$9,597.17
|
|
|
HEAD FEM COCR 12/14 28MM +3.5
|
Facility
|
IP
|
$4,693.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$610.19 |
| Max. Negotiated Rate |
$4,506.00 |
| Rate for Payer: Aetna Commercial |
$3,614.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,661.12
|
| Rate for Payer: Cash Price |
$2,346.88
|
| Rate for Payer: Cigna Commercial |
$3,895.81
|
| Rate for Payer: First Health Commercial |
$4,459.06
|
| Rate for Payer: Humana Commercial |
$3,989.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,848.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,463.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,408.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,130.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,520.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$938.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$610.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,455.06
|
| Rate for Payer: PHCS Commercial |
$4,506.00
|
| Rate for Payer: United Healthcare All Payer |
$4,130.50
|
|
|
HEAD FEM COCR 12/14 28MM +3.5
|
Facility
|
OP
|
$4,693.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$610.19 |
| Max. Negotiated Rate |
$4,506.00 |
| Rate for Payer: Aetna Commercial |
$3,614.19
|
| Rate for Payer: Anthem Medicaid |
$1,614.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,661.12
|
| Rate for Payer: Cash Price |
$2,346.88
|
| Rate for Payer: Cigna Commercial |
$3,895.81
|
| Rate for Payer: First Health Commercial |
$4,459.06
|
| Rate for Payer: Humana Commercial |
$3,989.69
|
| Rate for Payer: Humana KY Medicaid |
$1,614.18
|
| Rate for Payer: Kentucky WC Medicaid |
$1,630.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,848.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,463.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,408.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,646.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,130.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,520.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$938.75
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$610.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,455.06
|
| Rate for Payer: PHCS Commercial |
$4,506.00
|
| Rate for Payer: United Healthcare All Payer |
$4,130.50
|
|
|
HEAD FEMORAL V40 22MM
|
Facility
|
OP
|
$5,455.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$709.15 |
| Max. Negotiated Rate |
$5,236.80 |
| Rate for Payer: Aetna Commercial |
$4,200.35
|
| Rate for Payer: Anthem Medicaid |
$1,875.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,254.90
|
| Rate for Payer: Cash Price |
$2,727.50
|
| Rate for Payer: Cigna Commercial |
$4,527.65
|
| Rate for Payer: First Health Commercial |
$5,182.25
|
| Rate for Payer: Humana Commercial |
$4,636.75
|
| Rate for Payer: Humana KY Medicaid |
$1,875.97
|
| Rate for Payer: Kentucky WC Medicaid |
$1,895.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,473.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,025.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,636.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,913.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,800.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,091.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,091.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,691.05
|
| Rate for Payer: PHCS Commercial |
$5,236.80
|
| Rate for Payer: United Healthcare All Payer |
$4,800.40
|
|
|
HEAD FEMORAL V40 22MM
|
Facility
|
IP
|
$5,455.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$709.15 |
| Max. Negotiated Rate |
$5,236.80 |
| Rate for Payer: Aetna Commercial |
$4,200.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,254.90
|
| Rate for Payer: Cash Price |
$2,727.50
|
| Rate for Payer: Cigna Commercial |
$4,527.65
|
| Rate for Payer: First Health Commercial |
$5,182.25
|
| Rate for Payer: Humana Commercial |
$4,636.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,473.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,025.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,636.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,800.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,091.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,091.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,691.05
|
| Rate for Payer: PHCS Commercial |
$5,236.80
|
| Rate for Payer: United Healthcare All Payer |
$4,800.40
|
|
