|
INSERT RESTORATION ADM 28/60
|
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 28/60
|
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 28/64
|
Facility
|
OP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem Medicaid |
$3,291.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Humana KY Medicaid |
$3,291.12
|
| Rate for Payer: Kentucky WC Medicaid |
$3,324.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,357.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
INSERT RESTORATION ADM 28/64
|
Facility
|
IP
|
$9,570.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,871.00 |
| Max. Negotiated Rate |
$9,187.20 |
| Rate for Payer: Aetna Commercial |
$7,368.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,464.60
|
| Rate for Payer: Cash Price |
$4,785.00
|
| Rate for Payer: Cigna Commercial |
$7,943.10
|
| Rate for Payer: First Health Commercial |
$9,091.50
|
| Rate for Payer: Humana Commercial |
$8,134.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,847.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,062.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,871.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,421.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,177.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,656.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,325.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,603.30
|
| Rate for Payer: PHCS Commercial |
$9,187.20
|
| Rate for Payer: United Healthcare All Payer |
$8,421.60
|
|
|
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 |
$336.11 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$799.74
|
| Rate for Payer: Ambetter Exchange |
$336.11
|
| Rate for Payer: Anthem Medicaid |
$376.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$336.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$336.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$403.33
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$336.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.11
|
| 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 |
$436.94
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$336.11
|
|
|
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 |
$336.11 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$799.74
|
| Rate for Payer: Ambetter Exchange |
$336.11
|
| Rate for Payer: Anthem Medicaid |
$376.96
|
| Rate for Payer: Buckeye Individual/Medicaid |
$336.11
|
| Rate for Payer: Buckeye Medicare Advantage |
$336.11
|
| Rate for Payer: CareSource Just4Me Medicare |
$403.33
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$336.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.11
|
| 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 |
$436.94
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$380.73
|
| Rate for Payer: Wellcare Medicare Advantage |
$336.11
|
|
|
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 |
$480.00 |
| 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 |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| 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 |
$550.24 |
| Max. Negotiated Rate |
$29,035.76 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20,739.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$29,035.76
|
| Rate for Payer: CareSource Just4Me Medicare |
$27,998.77
|
| 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 |
$20,739.83
|
| 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 |
$24,887.80
|
| 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 |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
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 |
$156.59 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$313.67
|
| Rate for Payer: Ambetter Exchange |
$156.59
|
| Rate for Payer: Anthem Medicaid |
$194.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$156.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$156.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.91
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$156.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.59
|
| 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 |
$203.57
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$196.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$156.59
|
|
|
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 |
$156.59 |
| Max. Negotiated Rate |
$420.00 |
| Rate for Payer: Aetna Commercial |
$313.67
|
| Rate for Payer: Ambetter Exchange |
$156.59
|
| Rate for Payer: Anthem Medicaid |
$194.84
|
| Rate for Payer: Buckeye Individual/Medicaid |
$156.59
|
| Rate for Payer: Buckeye Medicare Advantage |
$156.59
|
| Rate for Payer: CareSource Just4Me Medicare |
$187.91
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$156.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$156.59
|
| 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 |
$203.57
|
| Rate for Payer: UHCCP Medicaid |
$245.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$196.79
|
| Rate for Payer: Wellcare Medicare Advantage |
$156.59
|
|
|
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 |
$240.73 |
| Max. Negotiated Rate |
$10,705.58 |
| Rate for Payer: Aetna Commercial |
$539.00
|
| Rate for Payer: Anthem Medicaid |
$240.73
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,646.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$546.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,705.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,323.23
|
| 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 |
$7,646.84
|
| 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 |
$9,176.21
|
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| Rate for Payer: PHCS Commercial |
$672.00
|
| Rate for Payer: United Healthcare All Payer |
$616.00
|
|
|
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 |
$210.00 |
| 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 |
$560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$483.00
|
| 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 |
$1,609.50 |
| Rate for Payer: Aetna Commercial |
$1,299.40
|
| Rate for Payer: Ambetter Exchange |
$952.62
|
| Rate for Payer: Anthem Medicaid |
$420.53
|
| Rate for Payer: Buckeye Individual/Medicaid |
$952.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$952.62
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,143.14
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$952.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$952.62
|
| 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 |
$1,238.41
|
| Rate for Payer: UHCCP Medicaid |
$938.88
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$424.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$952.62
|
|
|
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 |
$780.00 |
| Rate for Payer: Aetna Commercial |
$644.19
|
| Rate for Payer: Ambetter Exchange |
$344.07
|
| Rate for Payer: Anthem Medicaid |
$307.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$344.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$344.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$412.88
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$344.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.07
|
| 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 |
$447.29
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$310.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$344.07
|
|
|
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 |
$780.00 |
| Rate for Payer: Aetna Commercial |
$644.19
|
| Rate for Payer: Ambetter Exchange |
$344.07
|
| Rate for Payer: Anthem Medicaid |
$307.35
|
| Rate for Payer: Buckeye Individual/Medicaid |
$344.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$344.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$412.88
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$344.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$344.07
|
| 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 |
$447.29
|
| Rate for Payer: UHCCP Medicaid |
$455.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$310.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$344.07
|
|
|
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 |
$447.07 |
| Max. Negotiated Rate |
$10,705.58 |
| Rate for Payer: Aetna Commercial |
$1,001.00
|
| Rate for Payer: Anthem Medicaid |
$447.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,646.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,014.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,705.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,323.23
|
| 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 |
$7,646.84
|
| 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 |
$9,176.21
|
| 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 |
$1,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,131.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
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 |
$390.00 |
| 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 |
$1,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,131.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.00
|
| Rate for Payer: PHCS Commercial |
$1,248.00
|
| Rate for Payer: United Healthcare All Payer |
$1,144.00
|
|
|
INSERT TRANSVENOUS ELECTRODE
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 33216
|
| Hospital Charge Code |
76101250
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
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 |
$720.00 |
| Rate for Payer: Aetna Commercial |
$648.38
|
| Rate for Payer: Ambetter Exchange |
$345.89
|
| Rate for Payer: Anthem Medicaid |
$296.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$345.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$415.07
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$345.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.89
|
| 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 |
$449.66
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$345.89
|
|
|
INSERT TRANSVENOUS ELECTRODE
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 33216
|
| Hospital Charge Code |
76101250
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$412.68 |
| Max. Negotiated Rate |
$10,705.58 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$7,646.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$10,705.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$10,323.23
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Humana Medicare Advantage |
$7,646.84
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9,176.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
INSERT TRANSVENOUS ELECTRODE(P
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 33216
|
| Hospital Charge Code |
761P1250
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$296.78 |
| Max. Negotiated Rate |
$720.00 |
| Rate for Payer: Aetna Commercial |
$648.38
|
| Rate for Payer: Ambetter Exchange |
$345.89
|
| Rate for Payer: Anthem Medicaid |
$296.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$345.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$345.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$415.07
|
| 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: Medical Mutual Of Ohio Medicare Advantage |
$345.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$345.89
|
| 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 |
$449.66
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$299.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$345.89
|
|
|
INSERT TS TIBIAL #11/10MM
|
Facility
|
IP
|
$7,105.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.66 |
| Max. Negotiated Rate |
$6,821.30 |
| Rate for Payer: Aetna Commercial |
$5,471.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.31
|
| Rate for Payer: Cash Price |
$3,552.76
|
| Rate for Payer: Cigna Commercial |
$5,897.58
|
| Rate for Payer: First Health Commercial |
$6,750.24
|
| Rate for Payer: Humana Commercial |
$6,039.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,826.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,243.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,252.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,684.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,181.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,902.81
|
| Rate for Payer: PHCS Commercial |
$6,821.30
|
| Rate for Payer: United Healthcare All Payer |
$6,252.86
|
|
|
INSERT TS TIBIAL #11/10MM
|
Facility
|
OP
|
$7,105.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.66 |
| Max. Negotiated Rate |
$6,821.30 |
| Rate for Payer: Aetna Commercial |
$5,471.25
|
| Rate for Payer: Anthem Medicaid |
$2,443.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.31
|
| Rate for Payer: Cash Price |
$3,552.76
|
| Rate for Payer: Cigna Commercial |
$5,897.58
|
| Rate for Payer: First Health Commercial |
$6,750.24
|
| Rate for Payer: Humana Commercial |
$6,039.69
|
| Rate for Payer: Humana KY Medicaid |
$2,443.59
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,826.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,243.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,252.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,684.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,181.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,902.81
|
| Rate for Payer: PHCS Commercial |
$6,821.30
|
| Rate for Payer: United Healthcare All Payer |
$6,252.86
|
|
|
INSERT TS TIBIAL #11/10MM 9T
|
Facility
|
OP
|
$7,105.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.66 |
| Max. Negotiated Rate |
$6,821.30 |
| Rate for Payer: Aetna Commercial |
$5,471.25
|
| Rate for Payer: Anthem Medicaid |
$2,443.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.31
|
| Rate for Payer: Cash Price |
$3,552.76
|
| Rate for Payer: Cigna Commercial |
$5,897.58
|
| Rate for Payer: First Health Commercial |
$6,750.24
|
| Rate for Payer: Humana Commercial |
$6,039.69
|
| Rate for Payer: Humana KY Medicaid |
$2,443.59
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,826.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,243.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,252.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,684.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,181.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,902.81
|
| Rate for Payer: PHCS Commercial |
$6,821.30
|
| Rate for Payer: United Healthcare All Payer |
$6,252.86
|
|
|
INSERT TS TIBIAL #11/10MM 9T
|
Facility
|
IP
|
$7,105.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.66 |
| Max. Negotiated Rate |
$6,821.30 |
| Rate for Payer: Aetna Commercial |
$5,471.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.31
|
| Rate for Payer: Cash Price |
$3,552.76
|
| Rate for Payer: Cigna Commercial |
$5,897.58
|
| Rate for Payer: First Health Commercial |
$6,750.24
|
| Rate for Payer: Humana Commercial |
$6,039.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,826.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,243.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,252.86
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,684.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,181.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,902.81
|
| Rate for Payer: PHCS Commercial |
$6,821.30
|
| Rate for Payer: United Healthcare All Payer |
$6,252.86
|
|
