|
IMPLANT HORMONE PELLET(S)
|
Facility
|
OP
|
$763.00
|
|
|
Service Code
|
HCPCS 11980
|
| Hospital Charge Code |
76100116
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem Medicaid |
$262.40
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Humana KY Medicaid |
$262.40
|
| Rate for Payer: Humana Medicare Advantage |
$344.55
|
| Rate for Payer: Kentucky WC Medicaid |
$265.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$267.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
IMPLANT HORMONE PELLET(S)
|
Facility
|
IP
|
$763.00
|
|
|
Service Code
|
HCPCS 11980
|
| Hospital Charge Code |
76100116
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$99.19 |
| Max. Negotiated Rate |
$732.48 |
| Rate for Payer: Aetna Commercial |
$587.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$595.14
|
| Rate for Payer: Cash Price |
$381.50
|
| Rate for Payer: Cigna Commercial |
$633.29
|
| Rate for Payer: First Health Commercial |
$724.85
|
| Rate for Payer: Humana Commercial |
$648.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$625.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$563.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$228.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$671.44
|
| Rate for Payer: Ohio Health Group HMO |
$572.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$152.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$236.53
|
| Rate for Payer: PHCS Commercial |
$732.48
|
| Rate for Payer: United Healthcare All Payer |
$671.44
|
|
|
IMPLANT HORMONE PELLET(S)(P
|
Professional
|
Both
|
$220.00
|
|
|
Service Code
|
HCPCS 11980
|
| Hospital Charge Code |
761P0116
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$51.38 |
| Max. Negotiated Rate |
$220.00 |
| Rate for Payer: Aetna Commercial |
$122.00
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$55.37
|
| Rate for Payer: Anthem Medicaid |
$51.38
|
| Rate for Payer: Buckeye Medicare Advantage |
$220.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna Commercial |
$146.54
|
| Rate for Payer: Healthspan PPO |
$121.08
|
| Rate for Payer: Humana Medicaid |
$51.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$102.44
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$52.41
|
| Rate for Payer: Molina Healthcare Passport |
$51.38
|
| Rate for Payer: Multiplan PHCS |
$132.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$154.00
|
| Rate for Payer: UHCCP Medicaid |
$58.14
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$51.89
|
|
|
IMPLANT HORMONE PELLET(S)(T
|
Facility
|
OP
|
$543.00
|
|
|
Service Code
|
HCPCS 11980
|
| Hospital Charge Code |
761T0116
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.59 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem Medicaid |
$186.74
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.14
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Humana KY Medicaid |
$186.74
|
| Rate for Payer: Humana Medicare Advantage |
$344.55
|
| Rate for Payer: Kentucky WC Medicaid |
$188.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$190.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.33
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
IMPLANT HORMONE PELLET(S)(T
|
Facility
|
IP
|
$543.00
|
|
|
Service Code
|
HCPCS 11980
|
| Hospital Charge Code |
761T0116
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.59 |
| Max. Negotiated Rate |
$521.28 |
| Rate for Payer: Aetna Commercial |
$418.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$423.54
|
| Rate for Payer: Cash Price |
$271.50
|
| Rate for Payer: Cigna Commercial |
$450.69
|
| Rate for Payer: First Health Commercial |
$515.85
|
| Rate for Payer: Humana Commercial |
$461.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$445.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$400.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$162.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$477.84
|
| Rate for Payer: Ohio Health Group HMO |
$407.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$108.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$70.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$168.33
|
| Rate for Payer: PHCS Commercial |
$521.28
|
| Rate for Payer: United Healthcare All Payer |
$477.84
|
|
|
IMPLANT OS ANT FLNGE AUG 3.5MM
|
Facility
|
IP
|
$75,508.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,816.04 |
| Max. Negotiated Rate |
$72,487.68 |
| Rate for Payer: Aetna Commercial |
$58,141.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,896.24
|
| Rate for Payer: Cash Price |
$37,754.00
|
| Rate for Payer: Cigna Commercial |
$62,671.64
|
| Rate for Payer: First Health Commercial |
$71,732.60
|
| Rate for Payer: Humana Commercial |
$64,181.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,916.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,724.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,652.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,447.04
|
| Rate for Payer: Ohio Health Group HMO |
$56,631.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,101.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,816.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,407.48
|
| Rate for Payer: PHCS Commercial |
$72,487.68
|
| Rate for Payer: United Healthcare All Payer |
$66,447.04
|
|
|
IMPLANT OS ANT FLNGE AUG 3.5MM
|
Facility
|
OP
|
$75,508.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,816.04 |
| Max. Negotiated Rate |
$72,487.68 |
| Rate for Payer: Aetna Commercial |
$58,141.16
|
| Rate for Payer: Anthem Medicaid |
$25,967.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,896.24
|
| Rate for Payer: Cash Price |
$37,754.00
|
| Rate for Payer: Cigna Commercial |
$62,671.64
|
| Rate for Payer: First Health Commercial |
$71,732.60
|
| Rate for Payer: Humana Commercial |
$64,181.80
|
| Rate for Payer: Humana KY Medicaid |
$25,967.20
|
| Rate for Payer: Kentucky WC Medicaid |
$26,231.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,916.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,724.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,652.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,488.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$66,447.04
|
| Rate for Payer: Ohio Health Group HMO |
$56,631.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,101.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,816.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,407.48
|
| Rate for Payer: PHCS Commercial |
$72,487.68
|
| Rate for Payer: United Healthcare All Payer |
$66,447.04
|
|
|
IMPLANT OS RS RESURF FMRL 3 L
|
Facility
|
IP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 3 L
|
Facility
|
OP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem Medicaid |
$23,827.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Humana KY Medicaid |
$23,827.87
|
| Rate for Payer: Kentucky WC Medicaid |
$24,070.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,305.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 3 R
|
Facility
|
IP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 3 R
|
Facility
|
OP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem Medicaid |
$23,827.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Humana KY Medicaid |
$23,827.87
|
| Rate for Payer: Kentucky WC Medicaid |
$24,070.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,305.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 5 L
|
Facility
|
IP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 5 L
|
Facility
|
OP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem Medicaid |
$23,827.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Humana KY Medicaid |
$23,827.87
|
| Rate for Payer: Kentucky WC Medicaid |
$24,070.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,305.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 5 R
|
Facility
|
IP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OS RS RESURF FMRL 5 R
|
Facility
|
OP
|
$69,287.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,007.34 |
| Max. Negotiated Rate |
$66,515.71 |
| Rate for Payer: Aetna Commercial |
$53,351.14
|
| Rate for Payer: Anthem Medicaid |
$23,827.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,044.02
|
| Rate for Payer: Cash Price |
$34,643.60
|
| Rate for Payer: Cigna Commercial |
$57,508.38
|
| Rate for Payer: First Health Commercial |
$65,822.84
|
| Rate for Payer: Humana Commercial |
$58,894.12
|
| Rate for Payer: Humana KY Medicaid |
$23,827.87
|
| Rate for Payer: Kentucky WC Medicaid |
$24,070.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,815.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,133.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,786.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,305.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,972.74
|
| Rate for Payer: Ohio Health Group HMO |
$51,965.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,857.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,007.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,479.03
|
| Rate for Payer: PHCS Commercial |
$66,515.71
|
| Rate for Payer: United Healthcare All Payer |
$60,972.74
|
|
|
IMPLANT OSS RESRFCE FEM L 3CM
|
Facility
|
IP
|
$70,324.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,142.12 |
| Max. Negotiated Rate |
$67,511.04 |
| Rate for Payer: Aetna Commercial |
$54,149.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,852.72
|
| Rate for Payer: Cash Price |
$35,162.00
|
| Rate for Payer: Cigna Commercial |
$58,368.92
|
| Rate for Payer: First Health Commercial |
$66,807.80
|
| Rate for Payer: Humana Commercial |
$59,775.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,665.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,899.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,097.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$52,743.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,064.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,142.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,800.44
|
| Rate for Payer: PHCS Commercial |
$67,511.04
|
| Rate for Payer: United Healthcare All Payer |
$61,885.12
|
|
|
IMPLANT OSS RESRFCE FEM L 3CM
|
Facility
|
OP
|
$70,324.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,142.12 |
| Max. Negotiated Rate |
$67,511.04 |
| Rate for Payer: Aetna Commercial |
$54,149.48
|
| Rate for Payer: Anthem Medicaid |
$24,184.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,852.72
|
| Rate for Payer: Cash Price |
$35,162.00
|
| Rate for Payer: Cigna Commercial |
$58,368.92
|
| Rate for Payer: First Health Commercial |
$66,807.80
|
| Rate for Payer: Humana Commercial |
$59,775.40
|
| Rate for Payer: Humana KY Medicaid |
$24,184.42
|
| Rate for Payer: Kentucky WC Medicaid |
$24,430.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,665.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,899.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,097.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,669.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$52,743.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,064.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,142.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,800.44
|
| Rate for Payer: PHCS Commercial |
$67,511.04
|
| Rate for Payer: United Healthcare All Payer |
$61,885.12
|
|
|
IMPLANT OSS RESRFCE FEM R 3CM
|
Facility
|
IP
|
$70,324.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,142.12 |
| Max. Negotiated Rate |
$67,511.04 |
| Rate for Payer: Aetna Commercial |
$54,149.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,852.72
|
| Rate for Payer: Cash Price |
$35,162.00
|
| Rate for Payer: Cigna Commercial |
$58,368.92
|
| Rate for Payer: First Health Commercial |
$66,807.80
|
| Rate for Payer: Humana Commercial |
$59,775.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,665.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,899.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,097.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$52,743.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,064.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,142.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,800.44
|
| Rate for Payer: PHCS Commercial |
$67,511.04
|
| Rate for Payer: United Healthcare All Payer |
$61,885.12
|
|
|
IMPLANT OSS RESRFCE FEM R 3CM
|
Facility
|
OP
|
$70,324.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,142.12 |
| Max. Negotiated Rate |
$67,511.04 |
| Rate for Payer: Aetna Commercial |
$54,149.48
|
| Rate for Payer: Anthem Medicaid |
$24,184.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,852.72
|
| Rate for Payer: Cash Price |
$35,162.00
|
| Rate for Payer: Cigna Commercial |
$58,368.92
|
| Rate for Payer: First Health Commercial |
$66,807.80
|
| Rate for Payer: Humana Commercial |
$59,775.40
|
| Rate for Payer: Humana KY Medicaid |
$24,184.42
|
| Rate for Payer: Kentucky WC Medicaid |
$24,430.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$57,665.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,899.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21,097.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,669.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$52,743.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,064.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,142.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,800.44
|
| Rate for Payer: PHCS Commercial |
$67,511.04
|
| Rate for Payer: United Healthcare All Payer |
$61,885.12
|
|
|
IMPLANT OSS RESURFACING 3CM L
|
Facility
|
IP
|
$68,540.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,910.22 |
| Max. Negotiated Rate |
$65,798.55 |
| Rate for Payer: Aetna Commercial |
$52,775.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,461.32
|
| Rate for Payer: Cash Price |
$34,270.08
|
| Rate for Payer: Cigna Commercial |
$56,888.33
|
| Rate for Payer: First Health Commercial |
$65,113.15
|
| Rate for Payer: Humana Commercial |
$58,259.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,202.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,582.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,562.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,315.34
|
| Rate for Payer: Ohio Health Group HMO |
$51,405.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,708.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,910.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,247.45
|
| Rate for Payer: PHCS Commercial |
$65,798.55
|
| Rate for Payer: United Healthcare All Payer |
$60,315.34
|
|
|
IMPLANT OSS RESURFACING 3CM L
|
Facility
|
OP
|
$68,540.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,910.22 |
| Max. Negotiated Rate |
$65,798.55 |
| Rate for Payer: Aetna Commercial |
$52,775.92
|
| Rate for Payer: Anthem Medicaid |
$23,570.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,461.32
|
| Rate for Payer: Cash Price |
$34,270.08
|
| Rate for Payer: Cigna Commercial |
$56,888.33
|
| Rate for Payer: First Health Commercial |
$65,113.15
|
| Rate for Payer: Humana Commercial |
$58,259.14
|
| Rate for Payer: Humana KY Medicaid |
$23,570.96
|
| Rate for Payer: Kentucky WC Medicaid |
$23,810.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,202.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,582.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,562.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,043.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,315.34
|
| Rate for Payer: Ohio Health Group HMO |
$51,405.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,708.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,910.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,247.45
|
| Rate for Payer: PHCS Commercial |
$65,798.55
|
| Rate for Payer: United Healthcare All Payer |
$60,315.34
|
|
|
IMPLANT OSS RESURFACING 3CM R
|
Facility
|
IP
|
$68,540.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,910.22 |
| Max. Negotiated Rate |
$65,798.55 |
| Rate for Payer: Aetna Commercial |
$52,775.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,461.32
|
| Rate for Payer: Cash Price |
$34,270.08
|
| Rate for Payer: Cigna Commercial |
$56,888.33
|
| Rate for Payer: First Health Commercial |
$65,113.15
|
| Rate for Payer: Humana Commercial |
$58,259.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,202.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,582.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,562.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,315.34
|
| Rate for Payer: Ohio Health Group HMO |
$51,405.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,708.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,910.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,247.45
|
| Rate for Payer: PHCS Commercial |
$65,798.55
|
| Rate for Payer: United Healthcare All Payer |
$60,315.34
|
|
|
IMPLANT OSS RESURFACING 3CM R
|
Facility
|
OP
|
$68,540.16
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,910.22 |
| Max. Negotiated Rate |
$65,798.55 |
| Rate for Payer: Aetna Commercial |
$52,775.92
|
| Rate for Payer: Anthem Medicaid |
$23,570.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,461.32
|
| Rate for Payer: Cash Price |
$34,270.08
|
| Rate for Payer: Cigna Commercial |
$56,888.33
|
| Rate for Payer: First Health Commercial |
$65,113.15
|
| Rate for Payer: Humana Commercial |
$58,259.14
|
| Rate for Payer: Humana KY Medicaid |
$23,570.96
|
| Rate for Payer: Kentucky WC Medicaid |
$23,810.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,202.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,582.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,562.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,043.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,315.34
|
| Rate for Payer: Ohio Health Group HMO |
$51,405.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,708.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,910.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,247.45
|
| Rate for Payer: PHCS Commercial |
$65,798.55
|
| Rate for Payer: United Healthcare All Payer |
$60,315.34
|
|
|
IMPLANT OSS RESURFACING 5CM L
|
Facility
|
OP
|
$69,390.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,020.81 |
| Max. Negotiated Rate |
$66,615.18 |
| Rate for Payer: Aetna Commercial |
$53,430.92
|
| Rate for Payer: Anthem Medicaid |
$23,863.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,124.83
|
| Rate for Payer: Cash Price |
$34,695.40
|
| Rate for Payer: Cigna Commercial |
$57,594.37
|
| Rate for Payer: First Health Commercial |
$65,921.27
|
| Rate for Payer: Humana Commercial |
$58,982.19
|
| Rate for Payer: Humana KY Medicaid |
$23,863.50
|
| Rate for Payer: Kentucky WC Medicaid |
$24,106.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,900.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,210.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,817.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,342.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,063.91
|
| Rate for Payer: Ohio Health Group HMO |
$52,043.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,878.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,020.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,511.15
|
| Rate for Payer: PHCS Commercial |
$66,615.18
|
| Rate for Payer: United Healthcare All Payer |
$61,063.91
|
|
|
IMPLANT OSS RESURFACING 5CM L
|
Facility
|
IP
|
$69,390.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,020.81 |
| Max. Negotiated Rate |
$66,615.18 |
| Rate for Payer: Aetna Commercial |
$53,430.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$54,124.83
|
| Rate for Payer: Cash Price |
$34,695.40
|
| Rate for Payer: Cigna Commercial |
$57,594.37
|
| Rate for Payer: First Health Commercial |
$65,921.27
|
| Rate for Payer: Humana Commercial |
$58,982.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,900.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$51,210.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,817.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$61,063.91
|
| Rate for Payer: Ohio Health Group HMO |
$52,043.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,878.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,020.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,511.15
|
| Rate for Payer: PHCS Commercial |
$66,615.18
|
| Rate for Payer: United Healthcare All Payer |
$61,063.91
|
|
