|
LEGION XLPE DISH INST 3-4 13MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INST 3-4 13MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE DISH INST 3-4 15MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 3-4 15MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 5-6 11MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 5-6 11MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 5-6 13MM
|
Facility
|
IP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPE DISH INST 5-6 13MM
|
Facility
|
OP
|
$7,130.73
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$926.99 |
| Max. Negotiated Rate |
$6,845.50 |
| Rate for Payer: Aetna Commercial |
$5,490.66
|
| Rate for Payer: Anthem Medicaid |
$2,452.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,561.97
|
| Rate for Payer: Cash Price |
$3,565.36
|
| Rate for Payer: Cigna Commercial |
$5,918.51
|
| Rate for Payer: First Health Commercial |
$6,774.19
|
| Rate for Payer: Humana Commercial |
$6,061.12
|
| Rate for Payer: Humana KY Medicaid |
$2,452.26
|
| Rate for Payer: Kentucky WC Medicaid |
$2,477.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,847.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,262.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,139.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,501.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,275.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,348.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,426.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$926.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,210.53
|
| Rate for Payer: PHCS Commercial |
$6,845.50
|
| Rate for Payer: United Healthcare All Payer |
$6,275.04
|
|
|
LEGION XLPEPS INSRT SZ3-4 10MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPEPS INSRT SZ3-4 10MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE PSINSRT SZ3-4 12MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LEGION XLPE PSINSRT SZ3-4 12MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
LE INTRCL STR D TAIL ASSM 55MM
|
Facility
|
OP
|
$11,352.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,475.77 |
| Max. Negotiated Rate |
$10,898.00 |
| Rate for Payer: Aetna Commercial |
$8,741.10
|
| Rate for Payer: Anthem Medicaid |
$3,903.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,854.62
|
| Rate for Payer: Cash Price |
$5,676.04
|
| Rate for Payer: Cigna Commercial |
$9,422.23
|
| Rate for Payer: First Health Commercial |
$10,784.48
|
| Rate for Payer: Humana Commercial |
$9,649.27
|
| Rate for Payer: Humana KY Medicaid |
$3,903.98
|
| Rate for Payer: Kentucky WC Medicaid |
$3,943.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,308.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,377.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,982.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,989.83
|
| Rate for Payer: Ohio Health Group HMO |
$8,514.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,270.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,475.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,519.14
|
| Rate for Payer: PHCS Commercial |
$10,898.00
|
| Rate for Payer: United Healthcare All Payer |
$9,989.83
|
|
|
LE INTRCL STR D TAIL ASSM 55MM
|
Facility
|
IP
|
$11,352.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,475.77 |
| Max. Negotiated Rate |
$10,898.00 |
| Rate for Payer: Aetna Commercial |
$8,741.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,854.62
|
| Rate for Payer: Cash Price |
$5,676.04
|
| Rate for Payer: Cigna Commercial |
$9,422.23
|
| Rate for Payer: First Health Commercial |
$10,784.48
|
| Rate for Payer: Humana Commercial |
$9,649.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,308.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,377.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,989.83
|
| Rate for Payer: Ohio Health Group HMO |
$8,514.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,270.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,475.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,519.14
|
| Rate for Payer: PHCS Commercial |
$10,898.00
|
| Rate for Payer: United Healthcare All Payer |
$9,989.83
|
|
|
LEISHMANIASIS (VISCERAL) AB S
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
HCPCS 86717
|
| Hospital Charge Code |
30001193
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.25 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem Medicaid |
$12.25
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$12.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.83
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$17.15
|
| Rate for Payer: CareSource Just4Me Medicare |
$12.25
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$118.69
|
| Rate for Payer: First Health Commercial |
$135.85
|
| Rate for Payer: Humana Commercial |
$121.55
|
| Rate for Payer: Humana KY Medicaid |
$12.25
|
| Rate for Payer: Humana Medicare Advantage |
$12.25
|
| Rate for Payer: Kentucky WC Medicaid |
$12.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$14.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.84
|
| Rate for Payer: Ohio Health Group HMO |
$107.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.33
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
LEISHMANIASIS (VISCERAL) AB S
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS 86717
|
| Hospital Charge Code |
30001193
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.59 |
| Max. Negotiated Rate |
$137.28 |
| Rate for Payer: Aetna Commercial |
$110.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$114.83
|
| Rate for Payer: Cash Price |
$71.50
|
| Rate for Payer: Cigna Commercial |
$118.69
|
| Rate for Payer: First Health Commercial |
$135.85
|
| Rate for Payer: Humana Commercial |
$121.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$117.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$105.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$42.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$125.84
|
| Rate for Payer: Ohio Health Group HMO |
$107.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.33
|
| Rate for Payer: PHCS Commercial |
$137.28
|
| Rate for Payer: United Healthcare All Payer |
$125.84
|
|
|
LENEVA® 3CC
|
Facility
|
OP
|
$11,795.38
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
27000280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem Medicaid |
$4,056.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Humana KY Medicaid |
$4,056.43
|
| Rate for Payer: Kentucky WC Medicaid |
$4,097.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,137.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LENEVA® 3CC
|
Facility
|
IP
|
$11,795.38
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
27000280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LENGTHENING OF HAND TENDON
|
Facility
|
OP
|
$1,060.00
|
|
|
Service Code
|
HCPCS 26478
|
| Hospital Charge Code |
76100707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.80 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Aetna Commercial |
$816.20
|
| Rate for Payer: Anthem Medicaid |
$364.53
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$826.80
|
| 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 |
$530.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$879.80
|
| Rate for Payer: First Health Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial |
$901.00
|
| Rate for Payer: Humana KY Medicaid |
$364.53
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Kentucky WC Medicaid |
$368.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$869.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$782.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$371.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$932.80
|
| Rate for Payer: Ohio Health Group HMO |
$795.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$212.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$328.60
|
| Rate for Payer: PHCS Commercial |
$1,017.60
|
| Rate for Payer: United Healthcare All Payer |
$932.80
|
|
|
LENGTHENING OF HAND TENDON
|
Facility
|
IP
|
$1,060.00
|
|
|
Service Code
|
HCPCS 26478
|
| Hospital Charge Code |
76100707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$137.80 |
| Max. Negotiated Rate |
$1,017.60 |
| Rate for Payer: Aetna Commercial |
$816.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$826.80
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$879.80
|
| Rate for Payer: First Health Commercial |
$1,007.00
|
| Rate for Payer: Humana Commercial |
$901.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$869.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$782.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$318.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$932.80
|
| Rate for Payer: Ohio Health Group HMO |
$795.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$212.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$137.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$328.60
|
| Rate for Payer: PHCS Commercial |
$1,017.60
|
| Rate for Payer: United Healthcare All Payer |
$932.80
|
|
|
LENGTHENING OF HAND TENDON
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
HCPCS 26478
|
| Hospital Charge Code |
76100707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$297.74 |
| Max. Negotiated Rate |
$1,081.98 |
| Rate for Payer: Aetna Commercial |
$877.62
|
| Rate for Payer: Anthem Medicaid |
$297.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,060.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$1,081.98
|
| Rate for Payer: Healthspan PPO |
$794.93
|
| Rate for Payer: Humana Medicaid |
$297.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$752.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$303.69
|
| Rate for Payer: Molina Healthcare Passport |
$297.74
|
| Rate for Payer: Multiplan PHCS |
$636.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$742.00
|
| Rate for Payer: UHCCP Medicaid |
$371.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$300.72
|
|
|
LENGTHENING OF HAND TENDON(P
|
Professional
|
Both
|
$1,060.00
|
|
|
Service Code
|
HCPCS 26478
|
| Hospital Charge Code |
761P0707
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$297.74 |
| Max. Negotiated Rate |
$1,081.98 |
| Rate for Payer: Aetna Commercial |
$877.62
|
| Rate for Payer: Anthem Medicaid |
$297.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,060.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cash Price |
$530.00
|
| Rate for Payer: Cigna Commercial |
$1,081.98
|
| Rate for Payer: Healthspan PPO |
$794.93
|
| Rate for Payer: Humana Medicaid |
$297.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$752.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$303.69
|
| Rate for Payer: Molina Healthcare Passport |
$297.74
|
| Rate for Payer: Multiplan PHCS |
$636.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$742.00
|
| Rate for Payer: UHCCP Medicaid |
$371.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$300.72
|
|
|
LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$3,918.70
|
|
|
Service Code
|
CPT 27685
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,799.07 |
| Max. Negotiated Rate |
$3,918.70 |
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,799.07
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$3,918.70
|
| Rate for Payer: CareSource Just4Me Medicare |
$3,778.74
|
| Rate for Payer: Humana Medicare Advantage |
$2,799.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,358.88
|
|
|
LENS AC21D3 DIOPTER +15.0 (S)
|
Facility
|
OP
|
$1,875.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem Medicaid |
$644.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Humana KY Medicaid |
$644.81
|
| Rate for Payer: Kentucky WC Medicaid |
$651.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$657.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
|
LENS AC21D3 DIOPTER +15.0 (S)
|
Facility
|
IP
|
$1,875.00
|
|
|
Service Code
|
HCPCS V2630
|
| Hospital Charge Code |
27000069
|
|
Hospital Revenue Code
|
276
|
| Min. Negotiated Rate |
$243.75 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna Commercial |
$1,443.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,462.50
|
| Rate for Payer: Cash Price |
$937.50
|
| Rate for Payer: Cigna Commercial |
$1,556.25
|
| Rate for Payer: First Health Commercial |
$1,781.25
|
| Rate for Payer: Humana Commercial |
$1,593.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,537.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,383.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,650.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,406.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$375.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$581.25
|
| Rate for Payer: PHCS Commercial |
$1,800.00
|
| Rate for Payer: United Healthcare All Payer |
$1,650.00
|
|
