|
HEAD COCR MOD 36MM +9MM
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
HEAD COCR MOD 36MM +9MM
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
HEAD COCR MOD 36MM STD
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
HEAD COCR MOD 36MM STD
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
HEAD COCR MOD 44MM
|
Facility
|
IP
|
$13,409.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,022.70 |
| Max. Negotiated Rate |
$12,872.64 |
| Rate for Payer: Aetna Commercial |
$10,324.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,459.02
|
| Rate for Payer: Cash Price |
$6,704.50
|
| Rate for Payer: Cigna Commercial |
$11,129.47
|
| Rate for Payer: First Health Commercial |
$12,738.55
|
| Rate for Payer: Humana Commercial |
$11,397.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,995.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,895.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,022.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,799.92
|
| Rate for Payer: Ohio Health Group HMO |
$10,056.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,665.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,252.21
|
| Rate for Payer: PHCS Commercial |
$12,872.64
|
| Rate for Payer: United Healthcare All Payer |
$11,799.92
|
|
|
HEAD COCR MOD 44MM
|
Facility
|
OP
|
$13,409.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,022.70 |
| Max. Negotiated Rate |
$12,872.64 |
| Rate for Payer: Aetna Commercial |
$10,324.93
|
| Rate for Payer: Anthem Medicaid |
$4,611.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,459.02
|
| Rate for Payer: Cash Price |
$6,704.50
|
| Rate for Payer: Cigna Commercial |
$11,129.47
|
| Rate for Payer: First Health Commercial |
$12,738.55
|
| Rate for Payer: Humana Commercial |
$11,397.65
|
| Rate for Payer: Humana KY Medicaid |
$4,611.36
|
| Rate for Payer: Kentucky WC Medicaid |
$4,658.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,995.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,895.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,022.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,703.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,799.92
|
| Rate for Payer: Ohio Health Group HMO |
$10,056.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,727.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,665.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,252.21
|
| Rate for Payer: PHCS Commercial |
$12,872.64
|
| Rate for Payer: United Healthcare All Payer |
$11,799.92
|
|
|
HEAD ENDO II MOD SZ 41
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 41
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 42
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 42
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 43
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 43
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 44
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 44
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 45
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 45
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 46
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 46
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 47
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 47
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 48
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 48
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 49
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 49
|
Facility
|
OP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem Medicaid |
$1,229.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Humana KY Medicaid |
$1,229.44
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,254.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
|
HEAD ENDO II MOD SZ 50
|
Facility
|
IP
|
$3,575.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,072.50 |
| Max. Negotiated Rate |
$3,432.00 |
| Rate for Payer: Aetna Commercial |
$2,752.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,788.50
|
| Rate for Payer: Cash Price |
$1,787.50
|
| Rate for Payer: Cigna Commercial |
$2,967.25
|
| Rate for Payer: First Health Commercial |
$3,396.25
|
| Rate for Payer: Humana Commercial |
$3,038.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,931.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,638.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,072.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,146.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,681.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,860.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,110.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,466.75
|
| Rate for Payer: PHCS Commercial |
$3,432.00
|
| Rate for Payer: United Healthcare All Payer |
$3,146.00
|
|
