|
INSERT POLCUP PE NON-CEM 61/28
|
Facility
|
IP
|
$5,601.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$728.15 |
| Max. Negotiated Rate |
$5,377.08 |
| Rate for Payer: Aetna Commercial |
$4,312.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.87
|
| Rate for Payer: Cash Price |
$2,800.56
|
| Rate for Payer: Cigna Commercial |
$4,648.93
|
| Rate for Payer: First Health Commercial |
$5,321.06
|
| Rate for Payer: Humana Commercial |
$4,760.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,133.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.99
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$728.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.35
|
| Rate for Payer: PHCS Commercial |
$5,377.08
|
| Rate for Payer: United Healthcare All Payer |
$4,928.99
|
|
|
INSERT POLCUP PE NON-CEM 61/28
|
Facility
|
OP
|
$5,601.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$728.15 |
| Max. Negotiated Rate |
$5,377.08 |
| Rate for Payer: Aetna Commercial |
$4,312.86
|
| Rate for Payer: Anthem Medicaid |
$1,926.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.87
|
| Rate for Payer: Cash Price |
$2,800.56
|
| Rate for Payer: Cigna Commercial |
$4,648.93
|
| Rate for Payer: First Health Commercial |
$5,321.06
|
| Rate for Payer: Humana Commercial |
$4,760.95
|
| Rate for Payer: Humana KY Medicaid |
$1,926.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,945.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,133.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,964.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.99
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$728.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.35
|
| Rate for Payer: PHCS Commercial |
$5,377.08
|
| Rate for Payer: United Healthcare All Payer |
$4,928.99
|
|
|
INSERT POLCUP PE NON-CEM 63/28
|
Facility
|
IP
|
$5,601.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$728.15 |
| Max. Negotiated Rate |
$5,377.08 |
| Rate for Payer: Aetna Commercial |
$4,312.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.87
|
| Rate for Payer: Cash Price |
$2,800.56
|
| Rate for Payer: Cigna Commercial |
$4,648.93
|
| Rate for Payer: First Health Commercial |
$5,321.06
|
| Rate for Payer: Humana Commercial |
$4,760.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,133.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.99
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$728.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.35
|
| Rate for Payer: PHCS Commercial |
$5,377.08
|
| Rate for Payer: United Healthcare All Payer |
$4,928.99
|
|
|
INSERT POLCUP PE NON-CEM 63/28
|
Facility
|
OP
|
$5,601.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$728.15 |
| Max. Negotiated Rate |
$5,377.08 |
| Rate for Payer: Aetna Commercial |
$4,312.86
|
| Rate for Payer: Anthem Medicaid |
$1,926.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,368.87
|
| Rate for Payer: Cash Price |
$2,800.56
|
| Rate for Payer: Cigna Commercial |
$4,648.93
|
| Rate for Payer: First Health Commercial |
$5,321.06
|
| Rate for Payer: Humana Commercial |
$4,760.95
|
| Rate for Payer: Humana KY Medicaid |
$1,926.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,945.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,592.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,133.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,680.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,964.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,928.99
|
| Rate for Payer: Ohio Health Group HMO |
$4,200.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,120.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$728.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,736.35
|
| Rate for Payer: PHCS Commercial |
$5,377.08
|
| Rate for Payer: United Healthcare All Payer |
$4,928.99
|
|
|
INSERT POLCUP PE NON-CEM 65/28
|
Facility
|
IP
|
$6,524.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$848.23 |
| Max. Negotiated Rate |
$6,263.83 |
| Rate for Payer: Aetna Commercial |
$5,024.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,089.36
|
| Rate for Payer: Cash Price |
$3,262.41
|
| Rate for Payer: Cigna Commercial |
$5,415.60
|
| Rate for Payer: First Health Commercial |
$6,198.58
|
| Rate for Payer: Humana Commercial |
$5,546.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,350.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,815.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,957.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,741.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,893.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,304.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,022.69
|
| Rate for Payer: PHCS Commercial |
$6,263.83
|
| Rate for Payer: United Healthcare All Payer |
$5,741.84
|
|
|
INSERT POLCUP PE NON-CEM 65/28
|
Facility
|
OP
|
$6,524.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$848.23 |
| Max. Negotiated Rate |
$6,263.83 |
| Rate for Payer: Aetna Commercial |
$5,024.11
|
| Rate for Payer: Anthem Medicaid |
$2,243.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,089.36
|
| Rate for Payer: Cash Price |
$3,262.41
|
| Rate for Payer: Cigna Commercial |
$5,415.60
|
| Rate for Payer: First Health Commercial |
$6,198.58
|
| Rate for Payer: Humana Commercial |
$5,546.10
|
| Rate for Payer: Humana KY Medicaid |
$2,243.89
|
| Rate for Payer: Kentucky WC Medicaid |
$2,266.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,350.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,815.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,957.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,288.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,741.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,893.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,304.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,022.69
|
| Rate for Payer: PHCS Commercial |
$6,263.83
|
| Rate for Payer: United Healthcare All Payer |
$5,741.84
|
|
|
INSERT POLCUP PE NON-CEM 67/28
|
Facility
|
OP
|
$6,524.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$848.23 |
| Max. Negotiated Rate |
$6,263.83 |
| Rate for Payer: Aetna Commercial |
$5,024.11
|
| Rate for Payer: Anthem Medicaid |
$2,243.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,089.36
|
| Rate for Payer: Cash Price |
$3,262.41
|
| Rate for Payer: Cigna Commercial |
$5,415.60
|
| Rate for Payer: First Health Commercial |
$6,198.58
|
| Rate for Payer: Humana Commercial |
$5,546.10
|
| Rate for Payer: Humana KY Medicaid |
$2,243.89
|
| Rate for Payer: Kentucky WC Medicaid |
$2,266.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,350.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,815.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,957.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,288.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,741.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,893.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,304.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,022.69
|
| Rate for Payer: PHCS Commercial |
$6,263.83
|
| Rate for Payer: United Healthcare All Payer |
$5,741.84
|
|
|
INSERT POLCUP PE NON-CEM 67/28
|
Facility
|
IP
|
$6,524.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$848.23 |
| Max. Negotiated Rate |
$6,263.83 |
| Rate for Payer: Aetna Commercial |
$5,024.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,089.36
|
| Rate for Payer: Cash Price |
$3,262.41
|
| Rate for Payer: Cigna Commercial |
$5,415.60
|
| Rate for Payer: First Health Commercial |
$6,198.58
|
| Rate for Payer: Humana Commercial |
$5,546.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,350.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,815.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,957.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,741.84
|
| Rate for Payer: Ohio Health Group HMO |
$4,893.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,304.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,022.69
|
| Rate for Payer: PHCS Commercial |
$6,263.83
|
| Rate for Payer: United Healthcare All Payer |
$5,741.84
|
|
|
INSERT PROST URETHRAL STENT
|
Facility
|
OP
|
$4,310.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
76102122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.30 |
| Max. Negotiated Rate |
$4,137.60 |
| Rate for Payer: Aetna Commercial |
$3,318.70
|
| Rate for Payer: Anthem Medicaid |
$1,482.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,761.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,361.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,465.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,377.81
|
| Rate for Payer: Cash Price |
$2,155.00
|
| Rate for Payer: Cash Price |
$2,155.00
|
| Rate for Payer: Cigna Commercial |
$3,577.30
|
| Rate for Payer: First Health Commercial |
$4,094.50
|
| Rate for Payer: Humana Commercial |
$3,663.50
|
| Rate for Payer: Humana KY Medicaid |
$1,482.21
|
| Rate for Payer: Humana Medicare Advantage |
$1,761.34
|
| Rate for Payer: Kentucky WC Medicaid |
$1,497.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,534.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,180.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,511.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,792.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,232.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$862.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$560.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,336.10
|
| Rate for Payer: PHCS Commercial |
$4,137.60
|
| Rate for Payer: United Healthcare All Payer |
$3,792.80
|
|
|
INSERT PROST URETHRAL STENT
|
Professional
|
Both
|
$4,310.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
76102122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.53 |
| Max. Negotiated Rate |
$4,310.00 |
| Rate for Payer: Aetna Commercial |
$130.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.53
|
| Rate for Payer: Anthem Medicaid |
$63.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$4,310.00
|
| Rate for Payer: Cash Price |
$2,155.00
|
| Rate for Payer: Cash Price |
$2,155.00
|
| Rate for Payer: Cigna Commercial |
$1,002.45
|
| Rate for Payer: Healthspan PPO |
$613.52
|
| Rate for Payer: Humana Medicaid |
$63.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.32
|
| Rate for Payer: Molina Healthcare Passport |
$63.06
|
| Rate for Payer: Multiplan PHCS |
$2,586.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,017.00
|
| Rate for Payer: UHCCP Medicaid |
$43.61
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.69
|
|
|
INSERT PROST URETHRAL STENT
|
Facility
|
IP
|
$4,310.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
76102122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$560.30 |
| Max. Negotiated Rate |
$4,137.60 |
| Rate for Payer: Aetna Commercial |
$3,318.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,361.80
|
| Rate for Payer: Cash Price |
$2,155.00
|
| Rate for Payer: Cigna Commercial |
$3,577.30
|
| Rate for Payer: First Health Commercial |
$4,094.50
|
| Rate for Payer: Humana Commercial |
$3,663.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,534.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,180.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,293.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,792.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,232.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$862.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$560.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,336.10
|
| Rate for Payer: PHCS Commercial |
$4,137.60
|
| Rate for Payer: United Healthcare All Payer |
$3,792.80
|
|
|
INSERT PROST URETHRAL STENT(P
|
Professional
|
Both
|
$1,675.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
761P2122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$41.53 |
| Max. Negotiated Rate |
$1,675.00 |
| Rate for Payer: Aetna Commercial |
$130.82
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.53
|
| Rate for Payer: Anthem Medicaid |
$63.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,675.00
|
| Rate for Payer: Cash Price |
$837.50
|
| Rate for Payer: Cash Price |
$837.50
|
| Rate for Payer: Cigna Commercial |
$1,002.45
|
| Rate for Payer: Healthspan PPO |
$613.52
|
| Rate for Payer: Humana Medicaid |
$63.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$64.32
|
| Rate for Payer: Molina Healthcare Passport |
$63.06
|
| Rate for Payer: Multiplan PHCS |
$1,005.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,172.50
|
| Rate for Payer: UHCCP Medicaid |
$43.61
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$63.69
|
|
|
INSERT PROST URETHRAL STENT(T
|
Facility
|
OP
|
$2,635.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
761T2122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$342.55 |
| Max. Negotiated Rate |
$2,529.60 |
| Rate for Payer: Aetna Commercial |
$2,028.95
|
| Rate for Payer: Anthem Medicaid |
$906.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,761.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,055.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,465.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,377.81
|
| Rate for Payer: Cash Price |
$1,317.50
|
| Rate for Payer: Cash Price |
$1,317.50
|
| Rate for Payer: Cigna Commercial |
$2,187.05
|
| Rate for Payer: First Health Commercial |
$2,503.25
|
| Rate for Payer: Humana Commercial |
$2,239.75
|
| Rate for Payer: Humana KY Medicaid |
$906.18
|
| Rate for Payer: Humana Medicare Advantage |
$1,761.34
|
| Rate for Payer: Kentucky WC Medicaid |
$915.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,160.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,944.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,113.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$924.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,318.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,976.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$527.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$816.85
|
| Rate for Payer: PHCS Commercial |
$2,529.60
|
| Rate for Payer: United Healthcare All Payer |
$2,318.80
|
|
|
INSERT PROST URETHRAL STENT(T
|
Facility
|
IP
|
$2,635.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
761T2122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$342.55 |
| Max. Negotiated Rate |
$2,529.60 |
| Rate for Payer: Aetna Commercial |
$2,028.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,055.30
|
| Rate for Payer: Cash Price |
$1,317.50
|
| Rate for Payer: Cigna Commercial |
$2,187.05
|
| Rate for Payer: First Health Commercial |
$2,503.25
|
| Rate for Payer: Humana Commercial |
$2,239.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,160.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,944.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$790.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,318.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,976.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$527.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$342.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$816.85
|
| Rate for Payer: PHCS Commercial |
$2,529.60
|
| Rate for Payer: United Healthcare All Payer |
$2,318.80
|
|
|
INSERT PULSE GEN MULT LEADS
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
HCPCS 33221
|
| Hospital Charge Code |
76101253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$23,589.87 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem Medicaid |
$194.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16,849.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23,589.87
|
| Rate for Payer: CareSource Just4Me Medicare |
$22,747.38
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Humana KY Medicaid |
$194.30
|
| Rate for Payer: Humana Medicare Advantage |
$16,849.91
|
| Rate for Payer: Kentucky WC Medicaid |
$196.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,219.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$198.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
INSERT PULSE GEN MULT LEADS
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
HCPCS 33221
|
| Hospital Charge Code |
76101253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$73.45 |
| Max. Negotiated Rate |
$542.40 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$468.95
|
| Rate for Payer: First Health Commercial |
$536.75
|
| Rate for Payer: Humana Commercial |
$480.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$463.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$416.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$169.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$497.20
|
| Rate for Payer: Ohio Health Group HMO |
$423.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$113.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$73.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.15
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
INSERT PULSE GEN MULT LEADS
|
Professional
|
Both
|
$565.00
|
|
|
Service Code
|
HCPCS 33221
|
| Hospital Charge Code |
76101253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.75 |
| Max. Negotiated Rate |
$659.77 |
| Rate for Payer: Anthem Medicaid |
$284.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$565.00
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$659.77
|
| Rate for Payer: Healthspan PPO |
$443.22
|
| Rate for Payer: Humana Medicaid |
$284.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$474.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.21
|
| Rate for Payer: Molina Healthcare Passport |
$284.52
|
| Rate for Payer: Multiplan PHCS |
$339.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$395.50
|
| Rate for Payer: UHCCP Medicaid |
$197.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.37
|
|
|
INSERT PULSE GEN MULT LEADS(P
|
Professional
|
Both
|
$565.00
|
|
|
Service Code
|
HCPCS 33221
|
| Hospital Charge Code |
761P1253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$197.75 |
| Max. Negotiated Rate |
$659.77 |
| Rate for Payer: Anthem Medicaid |
$284.52
|
| Rate for Payer: Buckeye Medicare Advantage |
$565.00
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cash Price |
$282.50
|
| Rate for Payer: Cigna Commercial |
$659.77
|
| Rate for Payer: Healthspan PPO |
$443.22
|
| Rate for Payer: Humana Medicaid |
$284.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$474.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.21
|
| Rate for Payer: Molina Healthcare Passport |
$284.52
|
| Rate for Payer: Multiplan PHCS |
$339.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$395.50
|
| Rate for Payer: UHCCP Medicaid |
$197.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.37
|
|
|
INSERT RESTORATION ADM 28/46
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
INSERT RESTORATION ADM 28/46
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
INSERT RESTORATION ADM 28/48
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
INSERT RESTORATION ADM 28/48
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
INSERT RESTORATION ADM 28/50
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
INSERT RESTORATION ADM 28/50
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
INSERT RESTORATION ADM 28/52
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
