|
LATERAL CANTHOPEXY(T
|
Facility
|
OP
|
$4,476.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
761T0377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$581.88 |
| Max. Negotiated Rate |
$4,296.96 |
| Rate for Payer: Aetna Commercial |
$3,446.52
|
| Rate for Payer: Anthem Medicaid |
$1,539.30
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,784.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,491.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,897.84
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,758.63
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,715.08
|
| Rate for Payer: First Health Commercial |
$4,252.20
|
| Rate for Payer: Humana Commercial |
$3,804.60
|
| Rate for Payer: Humana KY Medicaid |
$1,539.30
|
| Rate for Payer: Humana Medicare Advantage |
$2,784.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,554.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,670.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,303.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,341.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,570.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,357.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,387.56
|
| Rate for Payer: PHCS Commercial |
$4,296.96
|
| Rate for Payer: United Healthcare All Payer |
$3,938.88
|
|
|
LATERAL CANTHOPEXY(T
|
Facility
|
IP
|
$4,476.00
|
|
|
Service Code
|
HCPCS 21282
|
| Hospital Charge Code |
761T0377
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$581.88 |
| Max. Negotiated Rate |
$4,296.96 |
| Rate for Payer: Aetna Commercial |
$3,446.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,491.28
|
| Rate for Payer: Cash Price |
$2,238.00
|
| Rate for Payer: Cigna Commercial |
$3,715.08
|
| Rate for Payer: First Health Commercial |
$4,252.20
|
| Rate for Payer: Humana Commercial |
$3,804.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,670.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,303.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,342.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,938.88
|
| Rate for Payer: Ohio Health Group HMO |
$3,357.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$895.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$581.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,387.56
|
| Rate for Payer: PHCS Commercial |
$4,296.96
|
| Rate for Payer: United Healthcare All Payer |
$3,938.88
|
|
|
LATERALIZD HUM CUP DIA 36+ 3MM
|
Facility
|
OP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem Medicaid |
$2,702.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Humana KY Medicaid |
$2,702.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,730.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,756.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 3MM
|
Facility
|
IP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 6MM
|
Facility
|
OP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem Medicaid |
$2,702.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Humana KY Medicaid |
$2,702.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,730.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,756.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 6MM
|
Facility
|
IP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 9MM
|
Facility
|
OP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem Medicaid |
$2,702.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Humana KY Medicaid |
$2,702.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,730.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,756.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 36+ 9MM
|
Facility
|
IP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 42+ 3MM
|
Facility
|
IP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
LATERALIZD HUM CUP DIA 42+ 3MM
|
Facility
|
OP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem Medicaid |
$2,544.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Humana KY Medicaid |
$2,544.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,570.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,595.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
LATERALIZD HUM CUP DIA 42+ 6MM
|
Facility
|
OP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem Medicaid |
$2,702.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Humana KY Medicaid |
$2,702.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,730.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,756.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 42+ 6MM
|
Facility
|
IP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATERALIZD HUM CUP DIA 42+ 9MM
|
Facility
|
OP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem Medicaid |
$2,544.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Humana KY Medicaid |
$2,544.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,570.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,595.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
LATERALIZD HUM CUP DIA 42+ 9MM
|
Facility
|
IP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
LAT RETINACULAR RELEASE OPEN
|
Facility
|
OP
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
76100841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$279.50 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$1,655.50
|
| Rate for Payer: Anthem Medicaid |
$739.38
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$1,784.50
|
| Rate for Payer: First Health Commercial |
$2,042.50
|
| Rate for Payer: Humana Commercial |
$1,827.50
|
| Rate for Payer: Humana KY Medicaid |
$739.38
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$746.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,586.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$754.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,892.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,612.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$279.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$666.50
|
| Rate for Payer: PHCS Commercial |
$2,064.00
|
| Rate for Payer: United Healthcare All Payer |
$1,892.00
|
|
|
LAT RETINACULAR RELEASE OPEN
|
Facility
|
IP
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
76100841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$279.50 |
| Max. Negotiated Rate |
$2,064.00 |
| Rate for Payer: Aetna Commercial |
$1,655.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,677.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$1,784.50
|
| Rate for Payer: First Health Commercial |
$2,042.50
|
| Rate for Payer: Humana Commercial |
$1,827.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,763.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,586.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$645.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,892.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,612.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$430.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$279.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$666.50
|
| Rate for Payer: PHCS Commercial |
$2,064.00
|
| Rate for Payer: United Healthcare All Payer |
$1,892.00
|
|
|
LAT RETINACULAR RELEASE OPEN
|
Professional
|
Both
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
76100841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.40 |
| Max. Negotiated Rate |
$2,150.00 |
| Rate for Payer: Aetna Commercial |
$634.87
|
| Rate for Payer: Anthem Medicaid |
$347.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,150.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$706.29
|
| Rate for Payer: Healthspan PPO |
$575.06
|
| Rate for Payer: Humana Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$545.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$354.35
|
| Rate for Payer: Molina Healthcare Passport |
$347.40
|
| Rate for Payer: Multiplan PHCS |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,505.00
|
| Rate for Payer: UHCCP Medicaid |
$752.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$350.87
|
|
|
LAT RETINACULAR RELEASE OPE(P
|
Professional
|
Both
|
$2,150.00
|
|
|
Service Code
|
HCPCS 27425
|
| Hospital Charge Code |
761P0841
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$347.40 |
| Max. Negotiated Rate |
$2,150.00 |
| Rate for Payer: Aetna Commercial |
$634.87
|
| Rate for Payer: Anthem Medicaid |
$347.40
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,150.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cash Price |
$1,075.00
|
| Rate for Payer: Cigna Commercial |
$706.29
|
| Rate for Payer: Healthspan PPO |
$575.06
|
| Rate for Payer: Humana Medicaid |
$347.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$545.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$354.35
|
| Rate for Payer: Molina Healthcare Passport |
$347.40
|
| Rate for Payer: Multiplan PHCS |
$1,290.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,505.00
|
| Rate for Payer: UHCCP Medicaid |
$752.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$350.87
|
|
|
LAT RETN HUM CUP DIA 36+ 6MM
|
Facility
|
IP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
LAT RETN HUM CUP DIA 36+ 6MM
|
Facility
|
OP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem Medicaid |
$2,544.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Humana KY Medicaid |
$2,544.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,570.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,595.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
LAT RETN HUM CUP DIA 42+ 6MM
|
Facility
|
IP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LAT RETN HUM CUP DIA 42+ 6MM
|
Facility
|
OP
|
$7,858.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,021.66 |
| Max. Negotiated Rate |
$7,544.54 |
| Rate for Payer: Aetna Commercial |
$6,051.35
|
| Rate for Payer: Anthem Medicaid |
$2,702.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,129.94
|
| Rate for Payer: Cash Price |
$3,929.45
|
| Rate for Payer: Cigna Commercial |
$6,522.89
|
| Rate for Payer: First Health Commercial |
$7,465.96
|
| Rate for Payer: Humana Commercial |
$6,680.06
|
| Rate for Payer: Humana KY Medicaid |
$2,702.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,730.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,444.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,799.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,357.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,756.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,915.83
|
| Rate for Payer: Ohio Health Group HMO |
$5,894.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,571.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,021.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,436.26
|
| Rate for Payer: PHCS Commercial |
$7,544.54
|
| Rate for Payer: United Healthcare All Payer |
$6,915.83
|
|
|
LATUDA 120 MG TABLET
|
Facility
|
IP
|
$142.59
|
|
|
Service Code
|
NDC 63402031230
|
| Hospital Charge Code |
25004056
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.54 |
| Max. Negotiated Rate |
$136.89 |
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.48
|
| Rate for Payer: Ohio Health Group HMO |
$106.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.20
|
| Rate for Payer: PHCS Commercial |
$136.89
|
| Rate for Payer: United Healthcare All Payer |
$125.48
|
| Rate for Payer: Aetna Commercial |
$109.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.22
|
| Rate for Payer: Cash Price |
$71.30
|
| Rate for Payer: Cigna Commercial |
$118.35
|
| Rate for Payer: First Health Commercial |
$135.46
|
| Rate for Payer: Humana Commercial |
$121.20
|
|
|
LATUDA 120 MG TABLET
|
Facility
|
OP
|
$142.59
|
|
|
Service Code
|
NDC 63402031230
|
| Hospital Charge Code |
25004056
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.54 |
| Max. Negotiated Rate |
$136.89 |
| Rate for Payer: Aetna Commercial |
$109.79
|
| Rate for Payer: Anthem Medicaid |
$49.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.22
|
| Rate for Payer: Cash Price |
$71.30
|
| Rate for Payer: Cigna Commercial |
$118.35
|
| Rate for Payer: First Health Commercial |
$135.46
|
| Rate for Payer: Humana Commercial |
$121.20
|
| Rate for Payer: Humana KY Medicaid |
$49.04
|
| Rate for Payer: Kentucky WC Medicaid |
$49.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$116.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.48
|
| Rate for Payer: Ohio Health Group HMO |
$106.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.20
|
| Rate for Payer: PHCS Commercial |
$136.89
|
| Rate for Payer: United Healthcare All Payer |
$125.48
|
|
|
LATUDA 20MG TABLET
|
Facility
|
IP
|
$85.29
|
|
|
Service Code
|
NDC 63402030230
|
| Hospital Charge Code |
25000846
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$81.88 |
| Rate for Payer: Aetna Commercial |
$65.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$66.53
|
| Rate for Payer: Cash Price |
$42.65
|
| Rate for Payer: Cigna Commercial |
$70.79
|
| Rate for Payer: First Health Commercial |
$81.03
|
| Rate for Payer: Humana Commercial |
$72.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$69.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$62.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.06
|
| Rate for Payer: Ohio Health Group HMO |
$63.97
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.44
|
| Rate for Payer: PHCS Commercial |
$81.88
|
| Rate for Payer: United Healthcare All Payer |
$75.06
|
|
