|
INSERT JRNY REV STD 7-8 R 11
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 13
|
Facility
|
IP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 13
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 15
|
Facility
|
IP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 15
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 18
|
Facility
|
IP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 18
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 9
|
Facility
|
OP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem Medicaid |
$3,218.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Humana KY Medicaid |
$3,218.32
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,282.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT JRNY REV STD 7-8 R 9
|
Facility
|
IP
|
$9,358.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.49 |
| Max. Negotiated Rate |
$8,983.97 |
| Rate for Payer: Aetna Commercial |
$7,205.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,299.47
|
| Rate for Payer: Cash Price |
$4,679.15
|
| Rate for Payer: Cigna Commercial |
$7,767.39
|
| Rate for Payer: First Health Commercial |
$8,890.39
|
| Rate for Payer: Humana Commercial |
$7,954.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,673.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,906.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,235.30
|
| Rate for Payer: Ohio Health Group HMO |
$7,018.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,486.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,141.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,457.23
|
| Rate for Payer: PHCS Commercial |
$8,983.97
|
| Rate for Payer: United Healthcare All Payer |
$8,235.30
|
|
|
INSERT MDM X3 22.2*36 SZ 36C
|
Facility
|
IP
|
$11,353.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,406.14 |
| Max. Negotiated Rate |
$10,899.65 |
| Rate for Payer: Aetna Commercial |
$8,742.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,855.96
|
| Rate for Payer: Cash Price |
$5,676.90
|
| Rate for Payer: Cigna Commercial |
$9,423.65
|
| Rate for Payer: First Health Commercial |
$10,786.11
|
| Rate for Payer: Humana Commercial |
$9,650.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,310.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,379.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,406.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,991.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,515.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,083.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,877.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,834.12
|
| Rate for Payer: PHCS Commercial |
$10,899.65
|
| Rate for Payer: United Healthcare All Payer |
$9,991.34
|
|
|
INSERT MDM X3 22.2*36 SZ 36C
|
Facility
|
OP
|
$11,353.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,406.14 |
| Max. Negotiated Rate |
$10,899.65 |
| Rate for Payer: Aetna Commercial |
$8,742.43
|
| Rate for Payer: Anthem Medicaid |
$3,904.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,855.96
|
| Rate for Payer: Cash Price |
$5,676.90
|
| Rate for Payer: Cigna Commercial |
$9,423.65
|
| Rate for Payer: First Health Commercial |
$10,786.11
|
| Rate for Payer: Humana Commercial |
$9,650.73
|
| Rate for Payer: Humana KY Medicaid |
$3,904.57
|
| Rate for Payer: Kentucky WC Medicaid |
$3,944.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,310.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,379.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,406.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,982.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,991.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,515.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,083.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,877.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,834.12
|
| Rate for Payer: PHCS Commercial |
$10,899.65
|
| Rate for Payer: United Healthcare All Payer |
$9,991.34
|
|
|
INSERT MDM X3 22.2*38 SZ 38D
|
Facility
|
IP
|
$11,353.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,406.14 |
| Max. Negotiated Rate |
$10,899.65 |
| Rate for Payer: Aetna Commercial |
$8,742.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,855.96
|
| Rate for Payer: Cash Price |
$5,676.90
|
| Rate for Payer: Cigna Commercial |
$9,423.65
|
| Rate for Payer: First Health Commercial |
$10,786.11
|
| Rate for Payer: Humana Commercial |
$9,650.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,310.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,379.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,406.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,991.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,515.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,083.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,877.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,834.12
|
| Rate for Payer: PHCS Commercial |
$10,899.65
|
| Rate for Payer: United Healthcare All Payer |
$9,991.34
|
|
|
INSERT MDM X3 22.2*38 SZ 38D
|
Facility
|
OP
|
$11,353.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,406.14 |
| Max. Negotiated Rate |
$10,899.65 |
| Rate for Payer: Aetna Commercial |
$8,742.43
|
| Rate for Payer: Anthem Medicaid |
$3,904.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,855.96
|
| Rate for Payer: Cash Price |
$5,676.90
|
| Rate for Payer: Cigna Commercial |
$9,423.65
|
| Rate for Payer: First Health Commercial |
$10,786.11
|
| Rate for Payer: Humana Commercial |
$9,650.73
|
| Rate for Payer: Humana KY Medicaid |
$3,904.57
|
| Rate for Payer: Kentucky WC Medicaid |
$3,944.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,310.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,379.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,406.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,982.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,991.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,515.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,083.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,877.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,834.12
|
| Rate for Payer: PHCS Commercial |
$10,899.65
|
| Rate for Payer: United Healthcare All Payer |
$9,991.34
|
|
|
INSERT MESH/PELVIC FLR ADDON
|
Facility
|
IP
|
$750.00
|
|
|
Service Code
|
HCPCS 57267
|
| Hospital Charge Code |
76102184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
INSERT MESH/PELVIC FLR ADDON
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 57267
|
| Hospital Charge Code |
76102184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$211.63 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$418.79
|
| Rate for Payer: Ambetter Exchange |
$237.09
|
| Rate for Payer: Anthem Medicaid |
$211.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$237.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$237.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$284.51
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$408.41
|
| Rate for Payer: Healthspan PPO |
$405.50
|
| Rate for Payer: Humana Medicaid |
$211.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$338.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$237.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$215.86
|
| Rate for Payer: Molina Healthcare Passport |
$211.63
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$308.22
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$213.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$237.09
|
|
|
INSERT MESH/PELVIC FLR ADDON
|
Facility
|
OP
|
$750.00
|
|
|
Service Code
|
HCPCS 57267
|
| Hospital Charge Code |
76102184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$577.50
|
| Rate for Payer: Anthem Medicaid |
$257.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$585.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$622.50
|
| Rate for Payer: First Health Commercial |
$712.50
|
| Rate for Payer: Humana Commercial |
$637.50
|
| Rate for Payer: Humana KY Medicaid |
$257.93
|
| Rate for Payer: Kentucky WC Medicaid |
$260.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$615.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$553.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$225.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$263.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$660.00
|
| Rate for Payer: Ohio Health Group HMO |
$562.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$600.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$652.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$517.50
|
| Rate for Payer: PHCS Commercial |
$720.00
|
| Rate for Payer: United Healthcare All Payer |
$660.00
|
|
|
INSERT MESH/PELVIC FLR ADDO(P
|
Professional
|
Both
|
$750.00
|
|
|
Service Code
|
HCPCS 57267
|
| Hospital Charge Code |
761P2184
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$211.63 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$418.79
|
| Rate for Payer: Ambetter Exchange |
$237.09
|
| Rate for Payer: Anthem Medicaid |
$211.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$237.09
|
| Rate for Payer: Buckeye Medicare Advantage |
$237.09
|
| Rate for Payer: CareSource Just4Me Medicare |
$284.51
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cash Price |
$375.00
|
| Rate for Payer: Cigna Commercial |
$408.41
|
| Rate for Payer: Healthspan PPO |
$405.50
|
| Rate for Payer: Humana Medicaid |
$211.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$338.77
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$237.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$237.09
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$215.86
|
| Rate for Payer: Molina Healthcare Passport |
$211.63
|
| Rate for Payer: Multiplan PHCS |
$450.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$308.22
|
| Rate for Payer: UHCCP Medicaid |
$262.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$213.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$237.09
|
|
|
INSERT MULTI-COMP PENIS PROS
|
Facility
|
IP
|
$815.00
|
|
|
Service Code
|
HCPCS 54405
|
| Hospital Charge Code |
76102865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$244.50 |
| Max. Negotiated Rate |
$782.40 |
| Rate for Payer: Aetna Commercial |
$627.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$635.70
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cigna Commercial |
$676.45
|
| Rate for Payer: First Health Commercial |
$774.25
|
| Rate for Payer: Humana Commercial |
$692.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.20
|
| Rate for Payer: Ohio Health Group HMO |
$611.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$652.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.35
|
| Rate for Payer: PHCS Commercial |
$782.40
|
| Rate for Payer: United Healthcare All Payer |
$717.20
|
|
|
INSERT MULTI-COMP PENIS PROS
|
Facility
|
OP
|
$815.00
|
|
|
Service Code
|
HCPCS 54405
|
| Hospital Charge Code |
76102865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$280.28 |
| Max. Negotiated Rate |
$26,037.75 |
| Rate for Payer: Aetna Commercial |
$627.55
|
| Rate for Payer: Anthem Medicaid |
$280.28
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18,598.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$635.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$26,037.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$25,107.83
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cigna Commercial |
$676.45
|
| Rate for Payer: First Health Commercial |
$774.25
|
| Rate for Payer: Humana Commercial |
$692.75
|
| Rate for Payer: Humana KY Medicaid |
$280.28
|
| Rate for Payer: Humana Medicare Advantage |
$18,598.39
|
| Rate for Payer: Kentucky WC Medicaid |
$283.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,318.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$285.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.20
|
| Rate for Payer: Ohio Health Group HMO |
$611.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$652.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.35
|
| Rate for Payer: PHCS Commercial |
$782.40
|
| Rate for Payer: United Healthcare All Payer |
$717.20
|
|
|
INSERT MULTI-COMP PENIS PROS
|
Professional
|
Both
|
$815.00
|
|
|
Service Code
|
HCPCS 54405
|
| Hospital Charge Code |
76102865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.25 |
| Max. Negotiated Rate |
$1,322.82 |
| Rate for Payer: Aetna Commercial |
$1,322.82
|
| Rate for Payer: Ambetter Exchange |
$764.85
|
| Rate for Payer: Anthem Medicaid |
$855.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$764.85
|
| Rate for Payer: Buckeye Medicare Advantage |
$764.85
|
| Rate for Payer: CareSource Just4Me Medicare |
$917.82
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cash Price |
$407.50
|
| Rate for Payer: Cigna Commercial |
$1,176.79
|
| Rate for Payer: Healthspan PPO |
$1,280.83
|
| Rate for Payer: Humana Medicaid |
$855.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,104.80
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$764.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$764.85
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$872.46
|
| Rate for Payer: Molina Healthcare Passport |
$855.35
|
| Rate for Payer: Multiplan PHCS |
$489.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$994.30
|
| Rate for Payer: UHCCP Medicaid |
$285.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$863.90
|
| Rate for Payer: Wellcare Medicare Advantage |
$764.85
|
|
|
INSERT NEEDLE BONE CAVITY
|
Facility
|
OP
|
$578.00
|
|
|
Service Code
|
HCPCS 36680
|
| Hospital Charge Code |
45000239
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$198.77 |
| Max. Negotiated Rate |
$554.88 |
| Rate for Payer: Aetna Commercial |
$445.06
|
| Rate for Payer: Anthem Medicaid |
$198.77
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$368.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.84
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$497.75
|
| Rate for Payer: Cash Price |
$289.00
|
| Rate for Payer: Cash Price |
$289.00
|
| Rate for Payer: Cigna Commercial |
$479.74
|
| Rate for Payer: First Health Commercial |
$549.10
|
| Rate for Payer: Humana Commercial |
$491.30
|
| Rate for Payer: Humana KY Medicaid |
$198.77
|
| Rate for Payer: Humana Medicare Advantage |
$368.70
|
| Rate for Payer: Kentucky WC Medicaid |
$200.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$426.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$202.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$508.64
|
| Rate for Payer: Ohio Health Group HMO |
$433.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.82
|
| Rate for Payer: PHCS Commercial |
$554.88
|
| Rate for Payer: United Healthcare All Payer |
$508.64
|
|
|
INSERT NEEDLE BONE CAVITY
|
Professional
|
Both
|
$559.00
|
|
|
Service Code
|
HCPCS 36680
|
| Hospital Charge Code |
76101502
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$56.74 |
| Max. Negotiated Rate |
$335.40 |
| Rate for Payer: Aetna Commercial |
$94.24
|
| Rate for Payer: Ambetter Exchange |
$56.74
|
| Rate for Payer: Anthem Medicaid |
$70.90
|
| Rate for Payer: Buckeye Individual/Medicaid |
$56.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$56.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$68.09
|
| Rate for Payer: Cash Price |
$279.50
|
| Rate for Payer: Cash Price |
$279.50
|
| Rate for Payer: Cigna Commercial |
$94.82
|
| Rate for Payer: Healthspan PPO |
$75.35
|
| Rate for Payer: Humana Medicaid |
$70.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$77.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$56.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$72.32
|
| Rate for Payer: Molina Healthcare Passport |
$70.90
|
| Rate for Payer: Multiplan PHCS |
$335.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$73.76
|
| Rate for Payer: UHCCP Medicaid |
$195.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$71.61
|
| Rate for Payer: Wellcare Medicare Advantage |
$56.74
|
|
|
INSERT NEEDLE BONE CAVITY
|
Facility
|
IP
|
$578.00
|
|
|
Service Code
|
HCPCS 36680
|
| Hospital Charge Code |
45000239
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$173.40 |
| Max. Negotiated Rate |
$554.88 |
| Rate for Payer: Aetna Commercial |
$445.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$450.84
|
| Rate for Payer: Cash Price |
$289.00
|
| Rate for Payer: Cigna Commercial |
$479.74
|
| Rate for Payer: First Health Commercial |
$549.10
|
| Rate for Payer: Humana Commercial |
$491.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$473.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$426.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$173.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$508.64
|
| Rate for Payer: Ohio Health Group HMO |
$433.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$462.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$502.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$398.82
|
| Rate for Payer: PHCS Commercial |
$554.88
|
| Rate for Payer: United Healthcare All Payer |
$508.64
|
|
|
INSERT NEEDLE BONE CAVITY
|
Facility
|
OP
|
$559.00
|
|
|
Service Code
|
HCPCS 36680
|
| Hospital Charge Code |
76101502
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$192.24 |
| Max. Negotiated Rate |
$536.64 |
| Rate for Payer: Aetna Commercial |
$430.43
|
| Rate for Payer: Anthem Medicaid |
$192.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$368.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$516.18
|
| Rate for Payer: CareSource Just4Me Medicare |
$497.75
|
| Rate for Payer: Cash Price |
$279.50
|
| Rate for Payer: Cash Price |
$279.50
|
| Rate for Payer: Cigna Commercial |
$463.97
|
| Rate for Payer: First Health Commercial |
$531.05
|
| Rate for Payer: Humana Commercial |
$475.15
|
| Rate for Payer: Humana KY Medicaid |
$192.24
|
| Rate for Payer: Humana Medicare Advantage |
$368.70
|
| Rate for Payer: Kentucky WC Medicaid |
$194.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$442.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$196.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.92
|
| Rate for Payer: Ohio Health Group HMO |
$419.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.71
|
| Rate for Payer: PHCS Commercial |
$536.64
|
| Rate for Payer: United Healthcare All Payer |
$491.92
|
|
|
INSERT NEEDLE BONE CAVITY
|
Facility
|
IP
|
$559.00
|
|
|
Service Code
|
HCPCS 36680
|
| Hospital Charge Code |
76101502
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$167.70 |
| Max. Negotiated Rate |
$536.64 |
| Rate for Payer: Aetna Commercial |
$430.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$436.02
|
| Rate for Payer: Cash Price |
$279.50
|
| Rate for Payer: Cigna Commercial |
$463.97
|
| Rate for Payer: First Health Commercial |
$531.05
|
| Rate for Payer: Humana Commercial |
$475.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$458.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$412.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$167.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$491.92
|
| Rate for Payer: Ohio Health Group HMO |
$419.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$447.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$486.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$385.71
|
| Rate for Payer: PHCS Commercial |
$536.64
|
| Rate for Payer: United Healthcare All Payer |
$491.92
|
|
