|
INSERT POLCUP PE NON-CEM 67/28
|
Facility
|
OP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem Medicaid |
$2,312.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Humana KY Medicaid |
$2,312.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,336.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,359.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT PROST URETHRAL STENT
|
Facility
|
OP
|
$4,310.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
76102122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,482.21 |
| 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 |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,361.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| 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 |
$1,892.78
|
| 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 |
$2,271.34
|
| 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 |
$3,448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,749.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,973.90
|
| Rate for Payer: PHCS Commercial |
$4,137.60
|
| Rate for Payer: United Healthcare All Payer |
$3,792.80
|
|
|
INSERT PROST URETHRAL STENT
|
Facility
|
IP
|
$4,310.00
|
|
|
Service Code
|
HCPCS 53855
|
| Hospital Charge Code |
76102122
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,293.00 |
| 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 |
$3,448.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,749.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,973.90
|
| 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 |
$2,586.00 |
| Rate for Payer: Aetna Commercial |
$130.82
|
| Rate for Payer: Ambetter Exchange |
$77.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.53
|
| Rate for Payer: Anthem Medicaid |
$465.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.54
|
| 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 |
$465.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$77.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$474.76
|
| Rate for Payer: Molina Healthcare Passport |
$465.45
|
| Rate for Payer: Multiplan PHCS |
$2,586.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.26
|
| Rate for Payer: UHCCP Medicaid |
$43.61
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$470.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.12
|
|
|
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 |
$1,005.00 |
| Rate for Payer: Aetna Commercial |
$130.82
|
| Rate for Payer: Ambetter Exchange |
$77.12
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$41.53
|
| Rate for Payer: Anthem Medicaid |
$465.45
|
| Rate for Payer: Buckeye Individual/Medicaid |
$77.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$77.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$92.54
|
| 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 |
$465.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$109.85
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$77.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$474.76
|
| Rate for Payer: Molina Healthcare Passport |
$465.45
|
| Rate for Payer: Multiplan PHCS |
$1,005.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$100.26
|
| Rate for Payer: UHCCP Medicaid |
$43.61
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$470.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$77.12
|
|
|
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 |
$790.50 |
| 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 |
$2,108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,292.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,818.15
|
| Rate for Payer: PHCS Commercial |
$2,529.60
|
| Rate for Payer: United Healthcare All Payer |
$2,318.80
|
|
|
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 |
$906.18 |
| Max. Negotiated Rate |
$2,649.89 |
| Rate for Payer: Aetna Commercial |
$2,028.95
|
| Rate for Payer: Anthem Medicaid |
$906.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,892.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,055.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,649.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,555.25
|
| 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 |
$1,892.78
|
| 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 |
$2,271.34
|
| 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 |
$2,108.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,292.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,818.15
|
| Rate for Payer: PHCS Commercial |
$2,529.60
|
| Rate for Payer: United Healthcare All Payer |
$2,318.80
|
|
|
INSERT PULSE GEN MULT LEADS
|
Facility
|
IP
|
$565.00
|
|
|
Service Code
|
HCPCS 33221
|
| Hospital Charge Code |
76101253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$169.50 |
| 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 |
$452.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$491.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.85
|
| 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: Ambetter Exchange |
$332.72
|
| Rate for Payer: Anthem Medicaid |
$284.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$332.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$332.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$399.26
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$332.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.72
|
| 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 |
$432.54
|
| Rate for Payer: UHCCP Medicaid |
$197.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$332.72
|
|
|
INSERT PULSE GEN MULT LEADS
|
Facility
|
OP
|
$565.00
|
|
|
Service Code
|
HCPCS 33221
|
| Hospital Charge Code |
76101253
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$194.30 |
| Max. Negotiated Rate |
$24,669.92 |
| Rate for Payer: Aetna Commercial |
$435.05
|
| Rate for Payer: Anthem Medicaid |
$194.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$17,621.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$440.70
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$24,669.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$23,788.85
|
| 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 |
$17,621.37
|
| 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 |
$21,145.64
|
| 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 |
$452.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$491.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$389.85
|
| Rate for Payer: PHCS Commercial |
$542.40
|
| Rate for Payer: United Healthcare All Payer |
$497.20
|
|
|
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: Ambetter Exchange |
$332.72
|
| Rate for Payer: Anthem Medicaid |
$284.52
|
| Rate for Payer: Buckeye Individual/Medicaid |
$332.72
|
| Rate for Payer: Buckeye Medicare Advantage |
$332.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$399.26
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$332.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$332.72
|
| 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 |
$432.54
|
| Rate for Payer: UHCCP Medicaid |
$197.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.37
|
| Rate for Payer: Wellcare Medicare Advantage |
$332.72
|
|
|
INSERT RESTORATION ADM 28/46
|
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 RESTORATION ADM 28/46
|
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 RESTORATION ADM 28/48
|
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 RESTORATION ADM 28/48
|
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 RESTORATION ADM 28/50
|
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 RESTORATION ADM 28/50
|
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 RESTORATION ADM 28/52
|
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 RESTORATION ADM 28/52
|
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 RESTORATION ADM 28/54
|
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 RESTORATION ADM 28/54
|
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 RESTORATION ADM 28/56
|
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 RESTORATION ADM 28/56
|
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 RESTORATION ADM 28/58
|
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 RESTORATION ADM 28/58
|
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
|
|
