|
MBT STEP WEDGE SZ 4 10MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 4 10MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 4 15MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 4 15MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 4 5MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 4 5MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 5 10MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 5 10MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 5 15MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 5 15MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 5 5MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 5 5MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 6 10MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 6 10MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 6 15MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 6 15MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 6 5MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MBT STEP WEDGE SZ 6 5MM
|
Facility
|
IP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
|
MCCALL COLPOPEXY
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44800
|
| Hospital Charge Code |
76101865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$463.75 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,092.57
|
| Rate for Payer: Anthem Medicaid |
$463.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,016.26
|
| Rate for Payer: Healthspan PPO |
$921.39
|
| Rate for Payer: Humana Medicaid |
$463.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$966.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.02
|
| Rate for Payer: Molina Healthcare Passport |
$463.75
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.39
|
|
|
MCCALL COLPOPEXY
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44800
|
| Hospital Charge Code |
76101865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
MCCALL COLPOPEXY
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44800
|
| Hospital Charge Code |
76101865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$208.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$208.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$496.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
MCCALL COLPOPEXY(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 44800
|
| Hospital Charge Code |
761P1865
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$463.75 |
| Max. Negotiated Rate |
$1,600.00 |
| Rate for Payer: Aetna Commercial |
$1,092.57
|
| Rate for Payer: Anthem Medicaid |
$463.75
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,600.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,016.26
|
| Rate for Payer: Healthspan PPO |
$921.39
|
| Rate for Payer: Humana Medicaid |
$463.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$966.46
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$473.02
|
| Rate for Payer: Molina Healthcare Passport |
$463.75
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,120.00
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$468.39
|
|
|
MCR ANNL WELLNESS VISIT INT
|
Professional
|
Both
|
$299.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
51000325
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.65 |
| Max. Negotiated Rate |
$299.00 |
| Rate for Payer: Aetna Commercial |
$254.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$299.00
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$214.30
|
| Rate for Payer: Multiplan PHCS |
$179.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$209.30
|
| Rate for Payer: UHCCP Medicaid |
$104.65
|
|
|
MCR ANNL WELLNESS VISIT INT
|
Facility
|
OP
|
$299.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
51000325
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.87 |
| Max. Negotiated Rate |
$287.04 |
| Rate for Payer: Aetna Commercial |
$230.23
|
| Rate for Payer: Anthem Medicaid |
$102.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$233.22
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Cigna Commercial |
$248.17
|
| Rate for Payer: First Health Commercial |
$284.05
|
| Rate for Payer: Humana Commercial |
$254.15
|
| Rate for Payer: Humana KY Medicaid |
$102.83
|
| Rate for Payer: Kentucky WC Medicaid |
$103.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$245.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$220.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$89.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$104.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$263.12
|
| Rate for Payer: Ohio Health Group HMO |
$224.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$59.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$38.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$92.69
|
| Rate for Payer: PHCS Commercial |
$287.04
|
| Rate for Payer: United Healthcare All Payer |
$263.12
|
|
|
MCR ANNL WELLNESS VISIT INT
|
Professional
|
Both
|
$299.00
|
|
|
Service Code
|
HCPCS G0438
|
| Hospital Charge Code |
510P0325
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$104.65 |
| Max. Negotiated Rate |
$299.00 |
| Rate for Payer: Aetna Commercial |
$254.66
|
| Rate for Payer: Buckeye Medicare Advantage |
$299.00
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Cash Price |
$149.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$214.30
|
| Rate for Payer: Multiplan PHCS |
$179.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$209.30
|
| Rate for Payer: UHCCP Medicaid |
$104.65
|
|
