|
HEAD HUMERAL 56MM*24MM
|
Facility
|
OP
|
$7,982.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,394.68 |
| Max. Negotiated Rate |
$7,662.96 |
| Rate for Payer: Aetna Commercial |
$6,146.33
|
| Rate for Payer: Anthem Medicaid |
$2,745.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.15
|
| Rate for Payer: Cash Price |
$3,991.12
|
| Rate for Payer: Cigna Commercial |
$6,625.27
|
| Rate for Payer: First Health Commercial |
$7,583.14
|
| Rate for Payer: Humana Commercial |
$6,784.91
|
| Rate for Payer: Humana KY Medicaid |
$2,745.10
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,545.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,890.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,024.38
|
| Rate for Payer: Ohio Health Group HMO |
$5,986.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,385.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,944.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,507.75
|
| Rate for Payer: PHCS Commercial |
$7,662.96
|
| Rate for Payer: United Healthcare All Payer |
$7,024.38
|
|
|
HEAD HUMERAL 56MM*24MM
|
Facility
|
IP
|
$7,982.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,394.68 |
| Max. Negotiated Rate |
$7,662.96 |
| Rate for Payer: Aetna Commercial |
$6,146.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.15
|
| Rate for Payer: Cash Price |
$3,991.12
|
| Rate for Payer: Cigna Commercial |
$6,625.27
|
| Rate for Payer: First Health Commercial |
$7,583.14
|
| Rate for Payer: Humana Commercial |
$6,784.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,545.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,890.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,024.38
|
| Rate for Payer: Ohio Health Group HMO |
$5,986.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,385.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,944.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,507.75
|
| Rate for Payer: PHCS Commercial |
$7,662.96
|
| Rate for Payer: United Healthcare All Payer |
$7,024.38
|
|
|
HEAD LEGACY COCR 12/14 22MM +0
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 22MM +0
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 22MM +8
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 22MM +8
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 26MM +0
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 26MM +0
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 26MM +8
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 26MM +8
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM +0
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM +0
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM +4
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM +4
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM -4
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM -4
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM +8
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 28MM +8
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM +0
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM +0
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM +4
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM +4
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM -4
|
Facility
|
IP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM -4
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
|
HEAD LEGACY COCR 12/14 32MM +8
|
Facility
|
OP
|
$4,315.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,294.69 |
| Max. Negotiated Rate |
$4,143.00 |
| Rate for Payer: Aetna Commercial |
$3,323.03
|
| Rate for Payer: Anthem Medicaid |
$1,484.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,366.18
|
| Rate for Payer: Cash Price |
$2,157.81
|
| Rate for Payer: Cigna Commercial |
$3,581.96
|
| Rate for Payer: First Health Commercial |
$4,099.84
|
| Rate for Payer: Humana Commercial |
$3,668.28
|
| Rate for Payer: Humana KY Medicaid |
$1,484.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,499.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,538.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,184.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,294.69
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,513.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,797.75
|
| Rate for Payer: Ohio Health Group HMO |
$3,236.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,452.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,754.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,977.78
|
| Rate for Payer: PHCS Commercial |
$4,143.00
|
| Rate for Payer: United Healthcare All Payer |
$3,797.75
|
|
