|
INSERT DM XLPE 28/48
|
Facility
|
OP
|
$9,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.38 |
| Max. Negotiated Rate |
$8,820.00 |
| Rate for Payer: Aetna Commercial |
$7,074.38
|
| Rate for Payer: Anthem Medicaid |
$3,159.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,166.25
|
| Rate for Payer: Cash Price |
$4,593.75
|
| Rate for Payer: Cigna Commercial |
$7,625.62
|
| Rate for Payer: First Health Commercial |
$8,728.12
|
| Rate for Payer: Humana Commercial |
$7,809.38
|
| Rate for Payer: Humana KY Medicaid |
$3,159.58
|
| Rate for Payer: Kentucky WC Medicaid |
$3,191.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,533.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,780.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,756.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,222.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,085.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,848.12
|
| Rate for Payer: PHCS Commercial |
$8,820.00
|
| Rate for Payer: United Healthcare All Payer |
$8,085.00
|
|
|
INSERT DM XLPE 28/48
|
Facility
|
IP
|
$9,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.38 |
| Max. Negotiated Rate |
$8,820.00 |
| Rate for Payer: Aetna Commercial |
$7,074.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,166.25
|
| Rate for Payer: Cash Price |
$4,593.75
|
| Rate for Payer: Cigna Commercial |
$7,625.62
|
| Rate for Payer: First Health Commercial |
$8,728.12
|
| Rate for Payer: Humana Commercial |
$7,809.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,533.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,780.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,756.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,085.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,848.12
|
| Rate for Payer: PHCS Commercial |
$8,820.00
|
| Rate for Payer: United Healthcare All Payer |
$8,085.00
|
|
|
INSERT DM XLPE 28/50
|
Facility
|
OP
|
$9,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.38 |
| Max. Negotiated Rate |
$8,820.00 |
| Rate for Payer: Aetna Commercial |
$7,074.38
|
| Rate for Payer: Anthem Medicaid |
$3,159.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,166.25
|
| Rate for Payer: Cash Price |
$4,593.75
|
| Rate for Payer: Cigna Commercial |
$7,625.62
|
| Rate for Payer: First Health Commercial |
$8,728.12
|
| Rate for Payer: Humana Commercial |
$7,809.38
|
| Rate for Payer: Humana KY Medicaid |
$3,159.58
|
| Rate for Payer: Kentucky WC Medicaid |
$3,191.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,533.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,780.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,756.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,222.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,085.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,848.12
|
| Rate for Payer: PHCS Commercial |
$8,820.00
|
| Rate for Payer: United Healthcare All Payer |
$8,085.00
|
|
|
INSERT DM XLPE 28/50
|
Facility
|
IP
|
$9,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.38 |
| Max. Negotiated Rate |
$8,820.00 |
| Rate for Payer: Aetna Commercial |
$7,074.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,166.25
|
| Rate for Payer: Cash Price |
$4,593.75
|
| Rate for Payer: Cigna Commercial |
$7,625.62
|
| Rate for Payer: First Health Commercial |
$8,728.12
|
| Rate for Payer: Humana Commercial |
$7,809.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,533.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,780.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,756.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,085.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,848.12
|
| Rate for Payer: PHCS Commercial |
$8,820.00
|
| Rate for Payer: United Healthcare All Payer |
$8,085.00
|
|
|
INSERT DM XLPE 28/52
|
Facility
|
IP
|
$9,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.38 |
| Max. Negotiated Rate |
$8,820.00 |
| Rate for Payer: Aetna Commercial |
$7,074.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,166.25
|
| Rate for Payer: Cash Price |
$4,593.75
|
| Rate for Payer: Cigna Commercial |
$7,625.62
|
| Rate for Payer: First Health Commercial |
$8,728.12
|
| Rate for Payer: Humana Commercial |
$7,809.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,533.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,780.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,756.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,085.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,848.12
|
| Rate for Payer: PHCS Commercial |
$8,820.00
|
| Rate for Payer: United Healthcare All Payer |
$8,085.00
|
|
|
INSERT DM XLPE 28/52
|
Facility
|
OP
|
$9,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.38 |
| Max. Negotiated Rate |
$8,820.00 |
| Rate for Payer: Aetna Commercial |
$7,074.38
|
| Rate for Payer: Anthem Medicaid |
$3,159.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,166.25
|
| Rate for Payer: Cash Price |
$4,593.75
|
| Rate for Payer: Cigna Commercial |
$7,625.62
|
| Rate for Payer: First Health Commercial |
$8,728.12
|
| Rate for Payer: Humana Commercial |
$7,809.38
|
| Rate for Payer: Humana KY Medicaid |
$3,159.58
|
| Rate for Payer: Kentucky WC Medicaid |
$3,191.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,533.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,780.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,756.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,222.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,085.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,837.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,848.12
|
| Rate for Payer: PHCS Commercial |
$8,820.00
|
| Rate for Payer: United Healthcare All Payer |
$8,085.00
|
|
|
INSERT DRUG IMPLANT DEVICE
|
Facility
|
OP
|
$1,681.00
|
|
|
Service Code
|
HCPCS 11981
|
| Hospital Charge Code |
76100117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.46 |
| Max. Negotiated Rate |
$1,613.76 |
| Rate for Payer: Aetna Commercial |
$1,294.37
|
| Rate for Payer: Anthem Medicaid |
$578.10
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,311.18
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$840.50
|
| Rate for Payer: Cash Price |
$840.50
|
| Rate for Payer: Cigna Commercial |
$1,395.23
|
| Rate for Payer: First Health Commercial |
$1,596.95
|
| Rate for Payer: Humana Commercial |
$1,428.85
|
| Rate for Payer: Humana KY Medicaid |
$578.10
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$583.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,378.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,240.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,479.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$336.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$521.11
|
| Rate for Payer: PHCS Commercial |
$1,613.76
|
| Rate for Payer: United Healthcare All Payer |
$1,479.28
|
|
|
INSERT DRUG IMPLANT DEVICE
|
Facility
|
IP
|
$1,681.00
|
|
|
Service Code
|
HCPCS 11981
|
| Hospital Charge Code |
76100117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$218.53 |
| Max. Negotiated Rate |
$1,613.76 |
| Rate for Payer: Aetna Commercial |
$1,294.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,311.18
|
| Rate for Payer: Cash Price |
$840.50
|
| Rate for Payer: Cigna Commercial |
$1,395.23
|
| Rate for Payer: First Health Commercial |
$1,596.95
|
| Rate for Payer: Humana Commercial |
$1,428.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,378.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,240.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,479.28
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$336.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$218.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$521.11
|
| Rate for Payer: PHCS Commercial |
$1,613.76
|
| Rate for Payer: United Healthcare All Payer |
$1,479.28
|
|
|
INSERT DRUG IMPLANT DEVICE
|
Professional
|
Both
|
$1,681.00
|
|
|
Service Code
|
HCPCS 11981
|
| Hospital Charge Code |
76100117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.41 |
| Max. Negotiated Rate |
$1,681.00 |
| Rate for Payer: Aetna Commercial |
$127.70
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.41
|
| Rate for Payer: Anthem Medicaid |
$61.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,681.00
|
| Rate for Payer: Cash Price |
$840.50
|
| Rate for Payer: Cash Price |
$840.50
|
| Rate for Payer: Cigna Commercial |
$121.72
|
| Rate for Payer: Healthspan PPO |
$154.32
|
| Rate for Payer: Humana Medicaid |
$61.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$105.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.55
|
| Rate for Payer: Molina Healthcare Passport |
$61.32
|
| Rate for Payer: Multiplan PHCS |
$1,008.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,176.70
|
| Rate for Payer: UHCCP Medicaid |
$39.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.93
|
|
|
INSERT DRUG IMPLANT DEVICE(P
|
Professional
|
Both
|
$375.00
|
|
|
Service Code
|
HCPCS 11981
|
| Hospital Charge Code |
761P0117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$37.41 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Aetna Commercial |
$127.70
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$37.41
|
| Rate for Payer: Anthem Medicaid |
$61.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$375.00
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cash Price |
$187.50
|
| Rate for Payer: Cigna Commercial |
$121.72
|
| Rate for Payer: Healthspan PPO |
$154.32
|
| Rate for Payer: Humana Medicaid |
$61.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$105.42
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$62.55
|
| Rate for Payer: Molina Healthcare Passport |
$61.32
|
| Rate for Payer: Multiplan PHCS |
$225.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$262.50
|
| Rate for Payer: UHCCP Medicaid |
$39.28
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$61.93
|
|
|
INSERT DRUG IMPLANT DEVICE(T
|
Facility
|
OP
|
$1,306.00
|
|
|
Service Code
|
HCPCS 11981
|
| Hospital Charge Code |
761T0117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.46 |
| Max. Negotiated Rate |
$1,253.76 |
| Rate for Payer: Aetna Commercial |
$1,005.62
|
| Rate for Payer: Anthem Medicaid |
$449.13
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,018.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cigna Commercial |
$1,083.98
|
| Rate for Payer: First Health Commercial |
$1,240.70
|
| Rate for Payer: Humana Commercial |
$1,110.10
|
| Rate for Payer: Humana KY Medicaid |
$449.13
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$453.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,070.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$963.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$458.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,149.28
|
| Rate for Payer: Ohio Health Group HMO |
$979.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$404.86
|
| Rate for Payer: PHCS Commercial |
$1,253.76
|
| Rate for Payer: United Healthcare All Payer |
$1,149.28
|
|
|
INSERT DRUG IMPLANT DEVICE(T
|
Facility
|
IP
|
$1,306.00
|
|
|
Service Code
|
HCPCS 11981
|
| Hospital Charge Code |
761T0117
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.78 |
| Max. Negotiated Rate |
$1,253.76 |
| Rate for Payer: Aetna Commercial |
$1,005.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,018.68
|
| Rate for Payer: Cash Price |
$653.00
|
| Rate for Payer: Cigna Commercial |
$1,083.98
|
| Rate for Payer: First Health Commercial |
$1,240.70
|
| Rate for Payer: Humana Commercial |
$1,110.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,070.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$963.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$391.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,149.28
|
| Rate for Payer: Ohio Health Group HMO |
$979.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$261.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$404.86
|
| Rate for Payer: PHCS Commercial |
$1,253.76
|
| Rate for Payer: United Healthcare All Payer |
$1,149.28
|
|
|
INSERT ELECTRODE
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 33249
|
| Hospital Charge Code |
76101270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$39,829.45 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem Medicaid |
$1,375.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28,449.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39,829.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$38,406.97
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Humana KY Medicaid |
$1,375.60
|
| Rate for Payer: Humana Medicare Advantage |
$28,449.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,389.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34,139.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,403.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
INSERT ELECTRODE
|
Professional
|
Both
|
$4,000.00
|
|
|
Service Code
|
HCPCS 33249
|
| Hospital Charge Code |
76101270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$894.41 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$1,555.41
|
| Rate for Payer: Anthem Medicaid |
$894.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$1,447.25
|
| Rate for Payer: Healthspan PPO |
$1,529.27
|
| Rate for Payer: Humana Medicaid |
$894.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,286.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$912.30
|
| Rate for Payer: Molina Healthcare Passport |
$894.41
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,800.00
|
| Rate for Payer: UHCCP Medicaid |
$1,400.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$903.35
|
|
|
INSERT ELECTRODE
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 33249
|
| Hospital Charge Code |
76101270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$3,840.00 |
| Rate for Payer: Aetna Commercial |
$3,080.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,120.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$3,320.00
|
| Rate for Payer: First Health Commercial |
$3,800.00
|
| Rate for Payer: Humana Commercial |
$3,400.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,280.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,952.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,520.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$800.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$520.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,240.00
|
| Rate for Payer: PHCS Commercial |
$3,840.00
|
| Rate for Payer: United Healthcare All Payer |
$3,520.00
|
|
|
INSERT ELECTRODE(P
|
Professional
|
Both
|
$4,000.00
|
|
|
Service Code
|
HCPCS 33249
|
| Hospital Charge Code |
761P1270
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$894.41 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna Commercial |
$1,555.41
|
| Rate for Payer: Anthem Medicaid |
$894.41
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cash Price |
$2,000.00
|
| Rate for Payer: Cigna Commercial |
$1,447.25
|
| Rate for Payer: Healthspan PPO |
$1,529.27
|
| Rate for Payer: Humana Medicaid |
$894.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,286.45
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$912.30
|
| Rate for Payer: Molina Healthcare Passport |
$894.41
|
| Rate for Payer: Multiplan PHCS |
$2,400.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,800.00
|
| Rate for Payer: UHCCP Medicaid |
$1,400.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$903.35
|
|
|
INSERT EPICARDIAL ELECTRODE
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 33202
|
| Hospital Charge Code |
76101241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
INSERT EPICARDIAL ELECTRODE
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 33202
|
| Hospital Charge Code |
76101241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,316.19
|
| Rate for Payer: Anthem Medicaid |
$579.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,237.32
|
| Rate for Payer: Healthspan PPO |
$1,294.07
|
| Rate for Payer: Humana Medicaid |
$579.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,084.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$591.43
|
| Rate for Payer: Molina Healthcare Passport |
$579.83
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$585.63
|
|
|
INSERT EPICARDIAL ELECTRODE
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 33202
|
| Hospital Charge Code |
76101241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna Commercial |
$1,155.00
|
| Rate for Payer: Anthem Medicaid |
$515.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,245.00
|
| Rate for Payer: First Health Commercial |
$1,425.00
|
| Rate for Payer: Humana Commercial |
$1,275.00
|
| Rate for Payer: Humana KY Medicaid |
$515.85
|
| Rate for Payer: Kentucky WC Medicaid |
$521.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$300.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$195.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.00
|
| Rate for Payer: PHCS Commercial |
$1,440.00
|
| Rate for Payer: United Healthcare All Payer |
$1,320.00
|
|
|
INSERT EPICARDIAL ELECTRODE(P
|
Professional
|
Both
|
$1,500.00
|
|
|
Service Code
|
HCPCS 33202
|
| Hospital Charge Code |
761P1241
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna Commercial |
$1,316.19
|
| Rate for Payer: Anthem Medicaid |
$579.83
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,500.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cash Price |
$750.00
|
| Rate for Payer: Cigna Commercial |
$1,237.32
|
| Rate for Payer: Healthspan PPO |
$1,294.07
|
| Rate for Payer: Humana Medicaid |
$579.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,084.28
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$591.43
|
| Rate for Payer: Molina Healthcare Passport |
$579.83
|
| Rate for Payer: Multiplan PHCS |
$900.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,050.00
|
| Rate for Payer: UHCCP Medicaid |
$525.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$585.63
|
|
|
INSERT FLEX HI PS 1-2 10MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT FLEX HI PS 1-2 10MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT FLEX HI PS 1-2 12MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT FLEX HI PS 1-2 12MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT FLEX HI PS 3-4 10MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
