|
LUTONIX 018 DCB 6*100 5F
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
LUTONIX 018 DCB 6*100 5F
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
LUTONIX 018 DCB 6*150 5F
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
LUTONIX 018 DCB 6*150 5F
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
LUTONIX 018 DCB 6*220 5F
|
Facility
|
OP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem Medicaid |
$4,649.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Humana KY Medicaid |
$4,649.53
|
| Rate for Payer: Kentucky WC Medicaid |
$4,696.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
LUTONIX 018 DCB 6*220 5F
|
Facility
|
IP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
LUTONIX 018 DCB 6*300 5F
|
Facility
|
IP
|
$12,425.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,615.25 |
| Max. Negotiated Rate |
$11,928.00 |
| Rate for Payer: Aetna Commercial |
$9,567.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,691.50
|
| Rate for Payer: Cash Price |
$6,212.50
|
| Rate for Payer: Cigna Commercial |
$10,312.75
|
| Rate for Payer: First Health Commercial |
$11,803.75
|
| Rate for Payer: Humana Commercial |
$10,561.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,188.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,169.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,727.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,934.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,485.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,615.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.75
|
| Rate for Payer: PHCS Commercial |
$11,928.00
|
| Rate for Payer: United Healthcare All Payer |
$10,934.00
|
|
|
LUTONIX 018 DCB 6*300 5F
|
Facility
|
OP
|
$12,425.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,615.25 |
| Max. Negotiated Rate |
$11,928.00 |
| Rate for Payer: Aetna Commercial |
$9,567.25
|
| Rate for Payer: Anthem Medicaid |
$4,272.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,691.50
|
| Rate for Payer: Cash Price |
$6,212.50
|
| Rate for Payer: Cigna Commercial |
$10,312.75
|
| Rate for Payer: First Health Commercial |
$11,803.75
|
| Rate for Payer: Humana Commercial |
$10,561.25
|
| Rate for Payer: Humana KY Medicaid |
$4,272.96
|
| Rate for Payer: Kentucky WC Medicaid |
$4,316.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,188.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,169.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,727.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,358.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,934.00
|
| Rate for Payer: Ohio Health Group HMO |
$9,318.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,485.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,615.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.75
|
| Rate for Payer: PHCS Commercial |
$11,928.00
|
| Rate for Payer: United Healthcare All Payer |
$10,934.00
|
|
|
LUTONIX 018 DCB 6*40 5F
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 6*40 5F
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 6*60 5F
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 6*60 5F
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 6*80 5F
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
LUTONIX 018 DCB 6*80 5F
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
LUTONIX 018 DCB 7*100 5F
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 7*100 5F
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 7*150 5F
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
LUTONIX 018 DCB 7*150 5F
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
LUTONIX 018 DCB 7*220 5F
|
Facility
|
IP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
LUTONIX 018 DCB 7*220 5F
|
Facility
|
OP
|
$9,917.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,289.28 |
| Max. Negotiated Rate |
$9,520.80 |
| Rate for Payer: Aetna Commercial |
$7,636.48
|
| Rate for Payer: Anthem Medicaid |
$3,410.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,735.65
|
| Rate for Payer: Cash Price |
$4,958.75
|
| Rate for Payer: Cigna Commercial |
$8,231.52
|
| Rate for Payer: First Health Commercial |
$9,421.62
|
| Rate for Payer: Humana Commercial |
$8,429.88
|
| Rate for Payer: Humana KY Medicaid |
$3,410.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,445.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,132.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,319.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,975.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,479.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,727.40
|
| Rate for Payer: Ohio Health Group HMO |
$7,438.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,983.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,289.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,074.42
|
| Rate for Payer: PHCS Commercial |
$9,520.80
|
| Rate for Payer: United Healthcare All Payer |
$8,727.40
|
|
|
LUTONIX 018 DCB 7*40 5F
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 7*40 5F
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 7*60 5F
|
Facility
|
OP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem Medicaid |
$2,531.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Humana KY Medicaid |
$2,531.96
|
| Rate for Payer: Kentucky WC Medicaid |
$2,557.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,582.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 7*60 5F
|
Facility
|
IP
|
$7,362.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$957.12 |
| Max. Negotiated Rate |
$7,068.00 |
| Rate for Payer: Aetna Commercial |
$5,669.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,742.75
|
| Rate for Payer: Cash Price |
$3,681.25
|
| Rate for Payer: Cigna Commercial |
$6,110.88
|
| Rate for Payer: First Health Commercial |
$6,994.38
|
| Rate for Payer: Humana Commercial |
$6,258.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,037.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,433.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,208.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,479.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,521.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,472.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,282.38
|
| Rate for Payer: PHCS Commercial |
$7,068.00
|
| Rate for Payer: United Healthcare All Payer |
$6,479.00
|
|
|
LUTONIX 018 DCB 7*80 5F
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
