|
INSERT RESTORATION ADM 28/52
|
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 28/54
|
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 28/54
|
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 28/56
|
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 28/56
|
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 28/58
|
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 28/58
|
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 28/60
|
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 28/60
|
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 28/64
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
INSERT RESTORATION ADM 28/64
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
INSERT SNGLE OR DUAL CHAMB PAC
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33240
|
| Hospital Charge Code |
76101266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
INSERT SNGLE OR DUAL CHAMB PAC
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33240
|
| Hospital Charge Code |
76101266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$28,536.86 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20,383.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28,536.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$27,517.68
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$20,383.47
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24,460.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
INSERT SNGLE OR DUAL CHAMB PAC
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33240
|
| Hospital Charge Code |
76101266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.96 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$799.74
|
| Rate for Payer: Anthem Medicaid |
$376.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$751.31
|
| Rate for Payer: Healthspan PPO |
$786.30
|
| Rate for Payer: Humana Medicaid |
$376.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$655.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.50
|
| Rate for Payer: Molina Healthcare Passport |
$376.96
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.73
|
|
|
INSERT SNGLE OR DUAL CHAMB PAC
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 33240
|
| Hospital Charge Code |
761P1266
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.96 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$799.74
|
| Rate for Payer: Anthem Medicaid |
$376.96
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$751.31
|
| Rate for Payer: Healthspan PPO |
$786.30
|
| Rate for Payer: Humana Medicaid |
$376.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$655.60
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$384.50
|
| Rate for Payer: Molina Healthcare Passport |
$376.96
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.73
|
|
|
INSERT TEMP D CHAMBER PACE ELE
|
Facility
|
IP
|
$700.00
|
|
|
Service Code
|
HCPCS 33211
|
| Hospital Charge Code |
76101245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$210.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
INSERT TEMP D CHAMBER PACE ELE
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 33211
|
| Hospital Charge Code |
76101245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$194.84 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$313.67
|
| Rate for Payer: Anthem Medicaid |
$194.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$293.19
|
| Rate for Payer: Healthspan PPO |
$308.40
|
| Rate for Payer: Humana Medicaid |
$194.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$260.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$198.74
|
| Rate for Payer: Molina Healthcare Passport |
$194.84
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$196.79
|
|
|
INSERT TEMP D CHAMBER PACE ELE
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 33211
|
| Hospital Charge Code |
761P1245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$194.84 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna Commercial |
$313.67
|
| Rate for Payer: Anthem Medicaid |
$194.84
|
| Rate for Payer: Buckeye Medicare Advantage |
$700.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$293.19
|
| Rate for Payer: Healthspan PPO |
$308.40
|
| Rate for Payer: Humana Medicaid |
$194.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$260.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$198.74
|
| Rate for Payer: Molina Healthcare Passport |
$194.84
|
| Rate for Payer: Multiplan PHCS |
$420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$490.00
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$196.79
|
|
|
INSERT TEMP D CHAMBER PACE ELE
|
Facility
|
OP
|
$700.00
|
|
|
Service Code
|
HCPCS 33211
|
| Hospital Charge Code |
76101245
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$91.00 |
| Max. Negotiated Rate |
$10,285.34 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,346.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,285.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,918.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: Cigna Commercial |
$581.00
|
| Rate for Payer: First Health Commercial |
$665.00
|
| Rate for Payer: Humana Commercial |
$595.00
|
| Rate for Payer: Humana KY Medicaid |
$240.73
|
| Rate for Payer: Humana Medicare Advantage |
$7,346.67
|
| Rate for Payer: Kentucky WC Medicaid |
$243.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$574.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$516.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,816.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$245.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$616.00
|
| Rate for Payer: Ohio Health Group HMO |
$525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$91.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$217.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
INSERT TISSUE EXPAND,BREAST
|
Professional
|
Both
|
$2,682.50
|
|
|
Service Code
|
HCPCS 11960
|
| Hospital Charge Code |
76102673
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$420.53 |
| Max. Negotiated Rate |
$2,682.50 |
| Rate for Payer: Aetna Commercial |
$1,299.40
|
| Rate for Payer: Anthem Medicaid |
$420.53
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,682.50
|
| Rate for Payer: Cash Price |
$1,341.25
|
| Rate for Payer: Cash Price |
$1,341.25
|
| Rate for Payer: Cigna Commercial |
$1,236.64
|
| Rate for Payer: Healthspan PPO |
$1,038.99
|
| Rate for Payer: Humana Medicaid |
$420.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,113.64
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$428.94
|
| Rate for Payer: Molina Healthcare Passport |
$420.53
|
| Rate for Payer: Multiplan PHCS |
$1,609.50
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,877.75
|
| Rate for Payer: UHCCP Medicaid |
$938.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$424.74
|
|
|
INSERT TRANS ELECTRODE DUAL CH
|
Professional
|
Both
|
$1,300.00
|
|
|
Service Code
|
HCPCS 33217
|
| Hospital Charge Code |
761P1251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$307.35 |
| Max. Negotiated Rate |
$1,300.00 |
| Rate for Payer: Aetna Commercial |
$644.19
|
| Rate for Payer: Anthem Medicaid |
$307.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,300.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$616.08
|
| Rate for Payer: Healthspan PPO |
$633.37
|
| Rate for Payer: Humana Medicaid |
$307.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$528.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$313.50
|
| Rate for Payer: Molina Healthcare Passport |
$307.35
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$310.42
|
|
|
INSERT TRANS ELECTRODE DUAL CH
|
Facility
|
OP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 33217
|
| Hospital Charge Code |
76101251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$10,285.34 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem Medicaid |
$447.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,346.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,285.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$9,918.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Humana KY Medicaid |
$447.07
|
| Rate for Payer: Humana Medicare Advantage |
$7,346.67
|
| Rate for Payer: Kentucky WC Medicaid |
$451.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,816.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$456.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
INSERT TRANS ELECTRODE DUAL CH
|
Professional
|
Both
|
$1,300.00
|
|
|
Service Code
|
HCPCS 33217
|
| Hospital Charge Code |
76101251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$307.35 |
| Max. Negotiated Rate |
$1,300.00 |
| Rate for Payer: Aetna Commercial |
$644.19
|
| Rate for Payer: Anthem Medicaid |
$307.35
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,300.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$616.08
|
| Rate for Payer: Healthspan PPO |
$633.37
|
| Rate for Payer: Humana Medicaid |
$307.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$528.15
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$313.50
|
| Rate for Payer: Molina Healthcare Passport |
$307.35
|
| Rate for Payer: Multiplan PHCS |
$780.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$910.00
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$310.42
|
|
|
INSERT TRANS ELECTRODE DUAL CH
|
Facility
|
IP
|
$1,300.00
|
|
|
Service Code
|
HCPCS 33217
|
| Hospital Charge Code |
76101251
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$1,248.00 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Cash Price |
$650.00
|
| Rate for Payer: Cigna Commercial |
$1,079.00
|
| Rate for Payer: First Health Commercial |
$1,235.00
|
| Rate for Payer: Humana Commercial |
$1,105.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,066.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$959.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$390.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,144.00
|
| Rate for Payer: Ohio Health Group HMO |
$975.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$260.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$169.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$403.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
INSERT TRANSVENOUS ELECTRODE
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 33216
|
| Hospital Charge Code |
76101250
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$296.78 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$648.38
|
| Rate for Payer: Anthem Medicaid |
$296.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,200.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$616.13
|
| Rate for Payer: Healthspan PPO |
$637.48
|
| Rate for Payer: Humana Medicaid |
$296.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$531.22
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$302.72
|
| Rate for Payer: Molina Healthcare Passport |
$296.78
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$840.00
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.75
|
|
