|
INTERROGATE SUBQ DEFIB
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
HCPCS 93261
|
| Hospital Charge Code |
48000115
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$48.90 |
| Max. Negotiated Rate |
$156.48 |
| Rate for Payer: Aetna Commercial |
$125.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.14
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$135.29
|
| Rate for Payer: First Health Commercial |
$154.85
|
| Rate for Payer: Humana Commercial |
$138.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$48.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.44
|
| Rate for Payer: Ohio Health Group HMO |
$122.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$141.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.47
|
| Rate for Payer: PHCS Commercial |
$156.48
|
| Rate for Payer: United Healthcare All Payer |
$143.44
|
|
|
INTERROGATE SUBQ DEFIB
|
Professional
|
Both
|
$163.00
|
|
|
Service Code
|
HCPCS 93261
|
| Hospital Charge Code |
48000115
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$47.48 |
| Max. Negotiated Rate |
$102.82 |
| Rate for Payer: Ambetter Exchange |
$63.54
|
| Rate for Payer: Anthem Medicaid |
$47.48
|
| Rate for Payer: Buckeye Individual/Medicaid |
$63.54
|
| Rate for Payer: Buckeye Medicare Advantage |
$63.54
|
| Rate for Payer: CareSource Just4Me Medicare |
$76.25
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$102.82
|
| Rate for Payer: Humana Medicaid |
$47.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$54.40
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$63.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$63.54
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$48.43
|
| Rate for Payer: Molina Healthcare Passport |
$47.48
|
| Rate for Payer: Multiplan PHCS |
$97.80
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$82.60
|
| Rate for Payer: UHCCP Medicaid |
$57.05
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$47.95
|
| Rate for Payer: Wellcare Medicare Advantage |
$63.54
|
|
|
INTERROGATE SUBQ DEFIB
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
HCPCS 93261
|
| Hospital Charge Code |
48000115
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.46 |
| Max. Negotiated Rate |
$156.48 |
| Rate for Payer: Aetna Commercial |
$125.51
|
| Rate for Payer: Anthem Medicaid |
$56.06
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$127.14
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.52
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cash Price |
$81.50
|
| Rate for Payer: Cigna Commercial |
$135.29
|
| Rate for Payer: First Health Commercial |
$154.85
|
| Rate for Payer: Humana Commercial |
$138.55
|
| Rate for Payer: Humana KY Medicaid |
$56.06
|
| Rate for Payer: Humana Medicare Advantage |
$34.46
|
| Rate for Payer: Kentucky WC Medicaid |
$56.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$133.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$120.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$143.44
|
| Rate for Payer: Ohio Health Group HMO |
$122.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$130.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$141.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.47
|
| Rate for Payer: PHCS Commercial |
$156.48
|
| Rate for Payer: United Healthcare All Payer |
$143.44
|
|
|
INTERROG DEV EVAL ICPMS IP
|
Facility
|
OP
|
$235.00
|
|
|
Service Code
|
HCPCS 93290
|
| Hospital Charge Code |
48000085
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$34.46 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem Medicaid |
$80.82
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$34.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$48.24
|
| Rate for Payer: CareSource Just4Me Medicare |
$46.52
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Humana KY Medicaid |
$80.82
|
| Rate for Payer: Humana Medicare Advantage |
$34.46
|
| Rate for Payer: Kentucky WC Medicaid |
$81.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$82.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
INTERROG DEV EVAL ICPMS IP
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
HCPCS 93290
|
| Hospital Charge Code |
48000085
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$70.50 |
| Max. Negotiated Rate |
$225.60 |
| Rate for Payer: Aetna Commercial |
$180.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$183.30
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$195.05
|
| Rate for Payer: First Health Commercial |
$223.25
|
| Rate for Payer: Humana Commercial |
$199.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$192.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$173.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$70.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$206.80
|
| Rate for Payer: Ohio Health Group HMO |
$176.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$204.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$162.15
|
| Rate for Payer: PHCS Commercial |
$225.60
|
| Rate for Payer: United Healthcare All Payer |
$206.80
|
|
|
INTERROG DEV EVAL ICPMS IP
|
Professional
|
Both
|
$235.00
|
|
|
Service Code
|
HCPCS 93290
|
| Hospital Charge Code |
48000085
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$26.41 |
| Max. Negotiated Rate |
$141.00 |
| Rate for Payer: Aetna Commercial |
$53.04
|
| Rate for Payer: Ambetter Exchange |
$47.33
|
| Rate for Payer: Anthem Medicaid |
$26.41
|
| Rate for Payer: Buckeye Individual/Medicaid |
$47.33
|
| Rate for Payer: Buckeye Medicare Advantage |
$47.33
|
| Rate for Payer: CareSource Just4Me Medicare |
$56.80
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cash Price |
$117.50
|
| Rate for Payer: Cigna Commercial |
$53.05
|
| Rate for Payer: Healthspan PPO |
$49.85
|
| Rate for Payer: Humana Medicaid |
$26.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$27.43
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$47.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.33
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$26.94
|
| Rate for Payer: Molina Healthcare Passport |
$26.41
|
| Rate for Payer: Multiplan PHCS |
$141.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$61.53
|
| Rate for Payer: UHCCP Medicaid |
$82.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$26.67
|
| Rate for Payer: Wellcare Medicare Advantage |
$47.33
|
|
|
INTERROG DEV EVAL SCRMS IP
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 93291
|
| Hospital Charge Code |
48000086
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
INTERROG DEV EVAL SCRMS IP
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 93291
|
| Hospital Charge Code |
48000086
|
|
Hospital Revenue Code
|
480
|
| Min. Negotiated Rate |
$22.63 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$31.98
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$72.54
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.68
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.55
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$31.98
|
| Rate for Payer: Humana Medicare Advantage |
$22.63
|
| Rate for Payer: Kentucky WC Medicaid |
$32.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$32.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
INTERSPACE HIP SPC0022
|
Facility
|
IP
|
$18,534.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,560.20 |
| Max. Negotiated Rate |
$17,792.64 |
| Rate for Payer: Aetna Commercial |
$14,271.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,456.52
|
| Rate for Payer: Cash Price |
$9,267.00
|
| Rate for Payer: Cigna Commercial |
$15,383.22
|
| Rate for Payer: First Health Commercial |
$17,607.30
|
| Rate for Payer: Humana Commercial |
$15,753.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,197.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,678.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,560.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,309.92
|
| Rate for Payer: Ohio Health Group HMO |
$13,900.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,827.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,124.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,788.46
|
| Rate for Payer: PHCS Commercial |
$17,792.64
|
| Rate for Payer: United Healthcare All Payer |
$16,309.92
|
|
|
INTERSPACE HIP SPC0022
|
Facility
|
OP
|
$18,534.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,560.20 |
| Max. Negotiated Rate |
$17,792.64 |
| Rate for Payer: Aetna Commercial |
$14,271.18
|
| Rate for Payer: Anthem Medicaid |
$6,373.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,456.52
|
| Rate for Payer: Cash Price |
$9,267.00
|
| Rate for Payer: Cigna Commercial |
$15,383.22
|
| Rate for Payer: First Health Commercial |
$17,607.30
|
| Rate for Payer: Humana Commercial |
$15,753.90
|
| Rate for Payer: Humana KY Medicaid |
$6,373.84
|
| Rate for Payer: Kentucky WC Medicaid |
$6,438.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,197.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,678.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,560.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,501.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,309.92
|
| Rate for Payer: Ohio Health Group HMO |
$13,900.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,827.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,124.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,788.46
|
| Rate for Payer: PHCS Commercial |
$17,792.64
|
| Rate for Payer: United Healthcare All Payer |
$16,309.92
|
|
|
INTERSPACE KNEE LRG
|
Facility
|
IP
|
$15,722.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,716.60 |
| Max. Negotiated Rate |
$15,093.12 |
| Rate for Payer: Aetna Commercial |
$12,105.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,263.16
|
| Rate for Payer: Cash Price |
$7,861.00
|
| Rate for Payer: Cigna Commercial |
$13,049.26
|
| Rate for Payer: First Health Commercial |
$14,935.90
|
| Rate for Payer: Humana Commercial |
$13,363.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,892.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,602.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,835.36
|
| Rate for Payer: Ohio Health Group HMO |
$11,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,577.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,678.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,848.18
|
| Rate for Payer: PHCS Commercial |
$15,093.12
|
| Rate for Payer: United Healthcare All Payer |
$13,835.36
|
|
|
INTERSPACE KNEE LRG
|
Facility
|
OP
|
$15,722.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,716.60 |
| Max. Negotiated Rate |
$15,093.12 |
| Rate for Payer: Aetna Commercial |
$12,105.94
|
| Rate for Payer: Anthem Medicaid |
$5,406.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,263.16
|
| Rate for Payer: Cash Price |
$7,861.00
|
| Rate for Payer: Cigna Commercial |
$13,049.26
|
| Rate for Payer: First Health Commercial |
$14,935.90
|
| Rate for Payer: Humana Commercial |
$13,363.70
|
| Rate for Payer: Humana KY Medicaid |
$5,406.80
|
| Rate for Payer: Kentucky WC Medicaid |
$5,461.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,892.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,602.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,515.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,835.36
|
| Rate for Payer: Ohio Health Group HMO |
$11,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,577.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,678.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,848.18
|
| Rate for Payer: PHCS Commercial |
$15,093.12
|
| Rate for Payer: United Healthcare All Payer |
$13,835.36
|
|
|
INTERSPACE KNEE MED
|
Facility
|
OP
|
$18,127.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,438.10 |
| Max. Negotiated Rate |
$17,401.92 |
| Rate for Payer: Aetna Commercial |
$13,957.79
|
| Rate for Payer: Anthem Medicaid |
$6,233.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,139.06
|
| Rate for Payer: Cash Price |
$9,063.50
|
| Rate for Payer: Cigna Commercial |
$15,045.41
|
| Rate for Payer: First Health Commercial |
$17,220.65
|
| Rate for Payer: Humana Commercial |
$15,407.95
|
| Rate for Payer: Humana KY Medicaid |
$6,233.88
|
| Rate for Payer: Kentucky WC Medicaid |
$6,297.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,864.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,377.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,438.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,358.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,951.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,595.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,501.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,770.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,507.63
|
| Rate for Payer: PHCS Commercial |
$17,401.92
|
| Rate for Payer: United Healthcare All Payer |
$15,951.76
|
|
|
INTERSPACE KNEE MED
|
Facility
|
IP
|
$18,127.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,438.10 |
| Max. Negotiated Rate |
$17,401.92 |
| Rate for Payer: Aetna Commercial |
$13,957.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,139.06
|
| Rate for Payer: Cash Price |
$9,063.50
|
| Rate for Payer: Cigna Commercial |
$15,045.41
|
| Rate for Payer: First Health Commercial |
$17,220.65
|
| Rate for Payer: Humana Commercial |
$15,407.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,864.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,377.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,438.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,951.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,595.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,501.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,770.49
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,507.63
|
| Rate for Payer: PHCS Commercial |
$17,401.92
|
| Rate for Payer: United Healthcare All Payer |
$15,951.76
|
|
|
INTERSPACE KNEE SM
|
Facility
|
OP
|
$17,720.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,316.00 |
| Max. Negotiated Rate |
$17,011.20 |
| Rate for Payer: Aetna Commercial |
$13,644.40
|
| Rate for Payer: Anthem Medicaid |
$6,093.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,821.60
|
| Rate for Payer: Cash Price |
$8,860.00
|
| Rate for Payer: Cigna Commercial |
$14,707.60
|
| Rate for Payer: First Health Commercial |
$16,834.00
|
| Rate for Payer: Humana Commercial |
$15,062.00
|
| Rate for Payer: Humana KY Medicaid |
$6,093.91
|
| Rate for Payer: Kentucky WC Medicaid |
$6,155.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,530.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,077.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,316.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,216.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,593.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,290.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,416.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,226.80
|
| Rate for Payer: PHCS Commercial |
$17,011.20
|
| Rate for Payer: United Healthcare All Payer |
$15,593.60
|
|
|
INTERSPACE KNEE SM
|
Facility
|
IP
|
$17,720.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,316.00 |
| Max. Negotiated Rate |
$17,011.20 |
| Rate for Payer: Aetna Commercial |
$13,644.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,821.60
|
| Rate for Payer: Cash Price |
$8,860.00
|
| Rate for Payer: Cigna Commercial |
$14,707.60
|
| Rate for Payer: First Health Commercial |
$16,834.00
|
| Rate for Payer: Humana Commercial |
$15,062.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,530.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,077.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,316.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,593.60
|
| Rate for Payer: Ohio Health Group HMO |
$13,290.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,176.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,416.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,226.80
|
| Rate for Payer: PHCS Commercial |
$17,011.20
|
| Rate for Payer: United Healthcare All Payer |
$15,593.60
|
|
|
INTERSPACE KNEE XLRG
|
Facility
|
OP
|
$15,722.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,716.60 |
| Max. Negotiated Rate |
$15,093.12 |
| Rate for Payer: Aetna Commercial |
$12,105.94
|
| Rate for Payer: Anthem Medicaid |
$5,406.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,263.16
|
| Rate for Payer: Cash Price |
$7,861.00
|
| Rate for Payer: Cigna Commercial |
$13,049.26
|
| Rate for Payer: First Health Commercial |
$14,935.90
|
| Rate for Payer: Humana Commercial |
$13,363.70
|
| Rate for Payer: Humana KY Medicaid |
$5,406.80
|
| Rate for Payer: Kentucky WC Medicaid |
$5,461.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,892.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,602.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,515.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,835.36
|
| Rate for Payer: Ohio Health Group HMO |
$11,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,577.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,678.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,848.18
|
| Rate for Payer: PHCS Commercial |
$15,093.12
|
| Rate for Payer: United Healthcare All Payer |
$13,835.36
|
|
|
INTERSPACE KNEE XLRG
|
Facility
|
IP
|
$15,722.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,716.60 |
| Max. Negotiated Rate |
$15,093.12 |
| Rate for Payer: Aetna Commercial |
$12,105.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,263.16
|
| Rate for Payer: Cash Price |
$7,861.00
|
| Rate for Payer: Cigna Commercial |
$13,049.26
|
| Rate for Payer: First Health Commercial |
$14,935.90
|
| Rate for Payer: Humana Commercial |
$13,363.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,892.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,602.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,716.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,835.36
|
| Rate for Payer: Ohio Health Group HMO |
$11,791.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,577.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,678.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,848.18
|
| Rate for Payer: PHCS Commercial |
$15,093.12
|
| Rate for Payer: United Healthcare All Payer |
$13,835.36
|
|
|
INTERSPACE SHOULDER KIT 46MM
|
Facility
|
IP
|
$17,579.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.82 |
| Max. Negotiated Rate |
$16,876.22 |
| Rate for Payer: Aetna Commercial |
$13,536.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,711.93
|
| Rate for Payer: Cash Price |
$8,789.70
|
| Rate for Payer: Cigna Commercial |
$14,590.90
|
| Rate for Payer: First Health Commercial |
$16,700.43
|
| Rate for Payer: Humana Commercial |
$14,942.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,415.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,973.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,273.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,469.87
|
| Rate for Payer: Ohio Health Group HMO |
$13,184.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,063.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,294.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,129.79
|
| Rate for Payer: PHCS Commercial |
$16,876.22
|
| Rate for Payer: United Healthcare All Payer |
$15,469.87
|
|
|
INTERSPACE SHOULDER KIT 46MM
|
Facility
|
OP
|
$17,579.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,273.82 |
| Max. Negotiated Rate |
$16,876.22 |
| Rate for Payer: Aetna Commercial |
$13,536.14
|
| Rate for Payer: Anthem Medicaid |
$6,045.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,711.93
|
| Rate for Payer: Cash Price |
$8,789.70
|
| Rate for Payer: Cigna Commercial |
$14,590.90
|
| Rate for Payer: First Health Commercial |
$16,700.43
|
| Rate for Payer: Humana Commercial |
$14,942.49
|
| Rate for Payer: Humana KY Medicaid |
$6,045.56
|
| Rate for Payer: Kentucky WC Medicaid |
$6,107.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,415.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,973.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,273.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,166.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,469.87
|
| Rate for Payer: Ohio Health Group HMO |
$13,184.55
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,063.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,294.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,129.79
|
| Rate for Payer: PHCS Commercial |
$16,876.22
|
| Rate for Payer: United Healthcare All Payer |
$15,469.87
|
|
|
INTERSTIM ANTENNA 37092
|
Facility
|
IP
|
$1,504.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.20 |
| Max. Negotiated Rate |
$1,443.84 |
| Rate for Payer: Aetna Commercial |
$1,158.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,173.12
|
| Rate for Payer: Cash Price |
$752.00
|
| Rate for Payer: Cigna Commercial |
$1,248.32
|
| Rate for Payer: First Health Commercial |
$1,428.80
|
| Rate for Payer: Humana Commercial |
$1,278.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,233.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,109.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,323.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,308.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,037.76
|
| Rate for Payer: PHCS Commercial |
$1,443.84
|
| Rate for Payer: United Healthcare All Payer |
$1,323.52
|
|
|
INTERSTIM ANTENNA 37092
|
Facility
|
OP
|
$1,504.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.20 |
| Max. Negotiated Rate |
$1,443.84 |
| Rate for Payer: Aetna Commercial |
$1,158.08
|
| Rate for Payer: Anthem Medicaid |
$517.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,173.12
|
| Rate for Payer: Cash Price |
$752.00
|
| Rate for Payer: Cigna Commercial |
$1,248.32
|
| Rate for Payer: First Health Commercial |
$1,428.80
|
| Rate for Payer: Humana Commercial |
$1,278.40
|
| Rate for Payer: Humana KY Medicaid |
$517.23
|
| Rate for Payer: Kentucky WC Medicaid |
$522.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,233.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,109.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$451.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$527.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,323.52
|
| Rate for Payer: Ohio Health Group HMO |
$1,128.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,308.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,037.76
|
| Rate for Payer: PHCS Commercial |
$1,443.84
|
| Rate for Payer: United Healthcare All Payer |
$1,323.52
|
|
|
INTERSTIM LEAD 4.32MM 28CM
|
Facility
|
IP
|
$18,367.31
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,510.19 |
| Max. Negotiated Rate |
$17,632.62 |
| Rate for Payer: Aetna Commercial |
$14,142.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,326.50
|
| Rate for Payer: Cash Price |
$9,183.66
|
| Rate for Payer: Cigna Commercial |
$15,244.87
|
| Rate for Payer: First Health Commercial |
$17,448.94
|
| Rate for Payer: Humana Commercial |
$15,612.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,061.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,555.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,510.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,163.23
|
| Rate for Payer: Ohio Health Group HMO |
$13,775.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,693.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,979.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,673.44
|
| Rate for Payer: PHCS Commercial |
$17,632.62
|
| Rate for Payer: United Healthcare All Payer |
$16,163.23
|
|
|
INTERSTIM LEAD 4.32MM 28CM
|
Facility
|
OP
|
$18,367.31
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,510.19 |
| Max. Negotiated Rate |
$17,632.62 |
| Rate for Payer: Aetna Commercial |
$14,142.83
|
| Rate for Payer: Anthem Medicaid |
$6,316.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,326.50
|
| Rate for Payer: Cash Price |
$9,183.66
|
| Rate for Payer: Cigna Commercial |
$15,244.87
|
| Rate for Payer: First Health Commercial |
$17,448.94
|
| Rate for Payer: Humana Commercial |
$15,612.21
|
| Rate for Payer: Humana KY Medicaid |
$6,316.52
|
| Rate for Payer: Kentucky WC Medicaid |
$6,380.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,061.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,555.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,510.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,443.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,163.23
|
| Rate for Payer: Ohio Health Group HMO |
$13,775.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,693.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,979.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,673.44
|
| Rate for Payer: PHCS Commercial |
$17,632.62
|
| Rate for Payer: United Healthcare All Payer |
$16,163.23
|
|
|
INTERSTIM LEAD INTRODUCER KIT
|
Facility
|
IP
|
$3,050.00
|
|
|
Service Code
|
HCPCS C1778
|
| Hospital Charge Code |
27000060
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$915.00 |
| Max. Negotiated Rate |
$2,928.00 |
| Rate for Payer: Aetna Commercial |
$2,348.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,379.00
|
| Rate for Payer: Cash Price |
$1,525.00
|
| Rate for Payer: Cigna Commercial |
$2,531.50
|
| Rate for Payer: First Health Commercial |
$2,897.50
|
| Rate for Payer: Humana Commercial |
$2,592.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,501.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,250.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$915.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,684.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,287.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,440.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,653.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,104.50
|
| Rate for Payer: PHCS Commercial |
$2,928.00
|
| Rate for Payer: United Healthcare All Payer |
$2,684.00
|
|
