|
JOURNEY II CSTD ARTSZ 7-8*21 L
|
Facility
|
IP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ARTSZ 7-8*21 L
|
Facility
|
OP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem Medicaid |
$4,761.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Humana KY Medicaid |
$4,761.56
|
| Rate for Payer: Kentucky WC Medicaid |
$4,810.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,857.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ARTSZ 7-8*21 R
|
Facility
|
IP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ARTSZ 7-8*21 R
|
Facility
|
OP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem Medicaid |
$4,761.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Humana KY Medicaid |
$4,761.56
|
| Rate for Payer: Kentucky WC Medicaid |
$4,810.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,857.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ARTSZ 7-8*25 R
|
Facility
|
IP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ARTSZ 7-8*25 R
|
Facility
|
OP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem Medicaid |
$4,761.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Humana KY Medicaid |
$4,761.56
|
| Rate for Payer: Kentucky WC Medicaid |
$4,810.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,857.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ART SZ 7-8*9 L
|
Facility
|
IP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ART SZ 7-8*9 L
|
Facility
|
OP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem Medicaid |
$4,761.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Humana KY Medicaid |
$4,761.56
|
| Rate for Payer: Kentucky WC Medicaid |
$4,810.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,857.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ART SZ 7-8*9 R
|
Facility
|
IP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY II CSTD ART SZ 7-8*9 R
|
Facility
|
OP
|
$13,845.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,799.95 |
| Max. Negotiated Rate |
$13,291.93 |
| Rate for Payer: Aetna Commercial |
$10,661.24
|
| Rate for Payer: Anthem Medicaid |
$4,761.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,799.69
|
| Rate for Payer: Cash Price |
$6,922.88
|
| Rate for Payer: Cigna Commercial |
$11,491.98
|
| Rate for Payer: First Health Commercial |
$13,153.47
|
| Rate for Payer: Humana Commercial |
$11,768.90
|
| Rate for Payer: Humana KY Medicaid |
$4,761.56
|
| Rate for Payer: Kentucky WC Medicaid |
$4,810.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,353.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,218.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,153.73
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,857.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,184.27
|
| Rate for Payer: Ohio Health Group HMO |
$10,384.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,769.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,799.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,292.19
|
| Rate for Payer: PHCS Commercial |
$13,291.93
|
| Rate for Payer: United Healthcare All Payer |
$12,184.27
|
|
|
JOURNEY OX TROCH X-SM RT
|
Facility
|
IP
|
$10,782.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,401.72 |
| Max. Negotiated Rate |
$10,351.20 |
| Rate for Payer: Aetna Commercial |
$8,302.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,410.35
|
| Rate for Payer: Cash Price |
$5,391.25
|
| Rate for Payer: Cigna Commercial |
$8,949.48
|
| Rate for Payer: First Health Commercial |
$10,243.38
|
| Rate for Payer: Humana Commercial |
$9,165.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,841.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,957.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,234.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,488.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,086.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,156.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,401.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,342.58
|
| Rate for Payer: PHCS Commercial |
$10,351.20
|
| Rate for Payer: United Healthcare All Payer |
$9,488.60
|
|
|
JOURNEY OX TROCH X-SM RT
|
Facility
|
OP
|
$10,782.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,401.72 |
| Max. Negotiated Rate |
$10,351.20 |
| Rate for Payer: Aetna Commercial |
$8,302.52
|
| Rate for Payer: Anthem Medicaid |
$3,708.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,410.35
|
| Rate for Payer: Cash Price |
$5,391.25
|
| Rate for Payer: Cigna Commercial |
$8,949.48
|
| Rate for Payer: First Health Commercial |
$10,243.38
|
| Rate for Payer: Humana Commercial |
$9,165.12
|
| Rate for Payer: Humana KY Medicaid |
$3,708.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,745.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,841.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,957.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,234.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,782.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,488.60
|
| Rate for Payer: Ohio Health Group HMO |
$8,086.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,156.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,401.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,342.58
|
| Rate for Payer: PHCS Commercial |
$10,351.20
|
| Rate for Payer: United Healthcare All Payer |
$9,488.60
|
|
|
JOURNEY PAT BICONVEX 23MM SM
|
Facility
|
OP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem Medicaid |
$1,775.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Humana KY Medicaid |
$1,775.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,793.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,811.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
|
JOURNEY PAT BICONVEX 23MM SM
|
Facility
|
IP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
|
JOURNEY PAT BICONVEX 23MM STD
|
Facility
|
IP
|
$4,234.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$550.52 |
| Max. Negotiated Rate |
$4,065.37 |
| Rate for Payer: Aetna Commercial |
$3,260.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,303.11
|
| Rate for Payer: Cash Price |
$2,117.38
|
| Rate for Payer: Cigna Commercial |
$3,514.85
|
| Rate for Payer: First Health Commercial |
$4,023.02
|
| Rate for Payer: Humana Commercial |
$3,599.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,472.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,125.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,270.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,726.59
|
| Rate for Payer: Ohio Health Group HMO |
$3,176.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$550.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,312.78
|
| Rate for Payer: PHCS Commercial |
$4,065.37
|
| Rate for Payer: United Healthcare All Payer |
$3,726.59
|
|
|
JOURNEY PAT BICONVEX 23MM STD
|
Facility
|
OP
|
$4,234.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$550.52 |
| Max. Negotiated Rate |
$4,065.37 |
| Rate for Payer: Aetna Commercial |
$3,260.77
|
| Rate for Payer: Anthem Medicaid |
$1,456.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,303.11
|
| Rate for Payer: Cash Price |
$2,117.38
|
| Rate for Payer: Cigna Commercial |
$3,514.85
|
| Rate for Payer: First Health Commercial |
$4,023.02
|
| Rate for Payer: Humana Commercial |
$3,599.55
|
| Rate for Payer: Humana KY Medicaid |
$1,456.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,471.16
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,472.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,125.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,270.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,485.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,726.59
|
| Rate for Payer: Ohio Health Group HMO |
$3,176.07
|
| Rate for Payer: Ohio Health Group PPO Differential |
$846.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$550.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,312.78
|
| Rate for Payer: PHCS Commercial |
$4,065.37
|
| Rate for Payer: United Healthcare All Payer |
$3,726.59
|
|
|
JOURNEY PAT BICONVEX 26MM SM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
JOURNEY PAT BICONVEX 26MM SM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
JOURNEY PAT BICONVEX 26MM STD
|
Facility
|
OP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem Medicaid |
$1,775.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Humana KY Medicaid |
$1,775.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,793.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,811.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
|
JOURNEY PAT BICONVEX 26MM STD
|
Facility
|
IP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
|
JOURNEY PAT BICONVEX 29MM SM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
JOURNEY PAT BICONVEX 29MM SM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
JOURNEY PAT BICONVEX 29MM STD
|
Facility
|
IP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
|
JOURNEY PAT BICONVEX 29MM STD
|
Facility
|
OP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem Medicaid |
$1,775.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Humana KY Medicaid |
$1,775.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,793.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,811.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
|
JOURNEY PAT BICONVEX 32MM STD
|
Facility
|
OP
|
$5,163.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$671.20 |
| Max. Negotiated Rate |
$4,956.58 |
| Rate for Payer: Aetna Commercial |
$3,975.59
|
| Rate for Payer: Anthem Medicaid |
$1,775.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,027.22
|
| Rate for Payer: Cash Price |
$2,581.55
|
| Rate for Payer: Cigna Commercial |
$4,285.37
|
| Rate for Payer: First Health Commercial |
$4,904.94
|
| Rate for Payer: Humana Commercial |
$4,388.64
|
| Rate for Payer: Humana KY Medicaid |
$1,775.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,793.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,233.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,810.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,548.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,811.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,543.53
|
| Rate for Payer: Ohio Health Group HMO |
$3,872.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,032.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$671.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,600.56
|
| Rate for Payer: PHCS Commercial |
$4,956.58
|
| Rate for Payer: United Healthcare All Payer |
$4,543.53
|
|
