|
NJX SCLRSNT 1 INCMPTNT VEIN
|
Facility
|
OP
|
$1,125.00
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
76101461
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$866.25
|
| Rate for Payer: Anthem Medicaid |
$386.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$933.75
|
| Rate for Payer: First Health Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial |
$956.25
|
| Rate for Payer: Humana KY Medicaid |
$386.89
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$390.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$394.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.00
|
| Rate for Payer: Ohio Health Group HMO |
$843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.75
|
| Rate for Payer: PHCS Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare All Payer |
$990.00
|
|
|
NJX SCLRSNT 1 INCMPTNT VEIN
|
Facility
|
IP
|
$1,125.00
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
76101461
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$146.25 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna Commercial |
$866.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$877.50
|
| Rate for Payer: Cash Price |
$562.50
|
| Rate for Payer: Cigna Commercial |
$933.75
|
| Rate for Payer: First Health Commercial |
$1,068.75
|
| Rate for Payer: Humana Commercial |
$956.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$922.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$830.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$337.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$990.00
|
| Rate for Payer: Ohio Health Group HMO |
$843.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$225.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$146.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$348.75
|
| Rate for Payer: PHCS Commercial |
$1,080.00
|
| Rate for Payer: United Healthcare All Payer |
$990.00
|
|
|
NJX SCLRSNT 1 INCMPTNT VEIN
|
Professional
|
Both
|
$1,425.00
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
76101461
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.41 |
| Max. Negotiated Rate |
$1,425.00 |
| Rate for Payer: Aetna Commercial |
$107.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.41
|
| Rate for Payer: Anthem Medicaid |
$65.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,425.00
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cash Price |
$712.50
|
| Rate for Payer: Cigna Commercial |
$209.12
|
| Rate for Payer: Healthspan PPO |
$161.14
|
| Rate for Payer: Humana Medicaid |
$65.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.12
|
| Rate for Payer: Molina Healthcare Passport |
$65.80
|
| Rate for Payer: Multiplan PHCS |
$855.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$997.50
|
| Rate for Payer: UHCCP Medicaid |
$40.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.46
|
|
|
NJX SCLRSNT 1 INCMPTNT VEIN(P
|
Professional
|
Both
|
$275.00
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
761P1461
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$38.41 |
| Max. Negotiated Rate |
$275.00 |
| Rate for Payer: Aetna Commercial |
$107.33
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$38.41
|
| Rate for Payer: Anthem Medicaid |
$65.80
|
| Rate for Payer: Buckeye Medicare Advantage |
$275.00
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cash Price |
$137.50
|
| Rate for Payer: Cigna Commercial |
$209.12
|
| Rate for Payer: Healthspan PPO |
$161.14
|
| Rate for Payer: Humana Medicaid |
$65.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$91.92
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$67.12
|
| Rate for Payer: Molina Healthcare Passport |
$65.80
|
| Rate for Payer: Multiplan PHCS |
$165.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$192.50
|
| Rate for Payer: UHCCP Medicaid |
$40.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$66.46
|
|
|
NJX SCLRSNT 1 INCMPTNT VEIN(T
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
761T1461
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$255.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
NJX SCLRSNT 1 INCMPTNT VEIN(T
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
HCPCS 36470
|
| Hospital Charge Code |
761T1461
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$110.50 |
| Max. Negotiated Rate |
$816.00 |
| Rate for Payer: Aetna Commercial |
$654.50
|
| Rate for Payer: Anthem Medicaid |
$292.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$344.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$663.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$482.75
|
| Rate for Payer: CareSource Just4Me Medicare |
$465.51
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cash Price |
$425.00
|
| Rate for Payer: Cigna Commercial |
$705.50
|
| Rate for Payer: First Health Commercial |
$807.50
|
| Rate for Payer: Humana Commercial |
$722.50
|
| Rate for Payer: Humana KY Medicaid |
$292.32
|
| Rate for Payer: Humana Medicare Advantage |
$344.82
|
| Rate for Payer: Kentucky WC Medicaid |
$295.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$697.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$627.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$413.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$298.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$748.00
|
| Rate for Payer: Ohio Health Group HMO |
$637.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$170.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$110.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$263.50
|
| Rate for Payer: PHCS Commercial |
$816.00
|
| Rate for Payer: United Healthcare All Payer |
$748.00
|
|
|
NK REJUV MOD 30MM 127/132 0^ B
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 30MM 127/132 0^ B
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 30MM 127/132 8^ G
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 30MM 127/132 8^ G
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 30MM 127/132 8^ Y
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 30MM 127/132 8^ Y
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 34MM 127/132 0^ B
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 34MM 127/132 0^ B
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 34MM 127/132 8^ G
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 34MM 127/132 8^ G
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 34MM 127/132 8^ Y
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 34MM 127/132 8^ Y
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 38MM 127/132 0^ B
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 38MM 127/132 0^ B
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 38MM 127/132 8^ G
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 38MM 127/132 8^ G
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 38MM 127/132 8^ Y
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 38MM 127/132 8^ Y
|
Facility
|
OP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem Medicaid |
$1,624.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Humana KY Medicaid |
$1,624.41
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,657.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
|
NK REJUV MOD 42MM 127/132 0^ B
|
Facility
|
IP
|
$4,723.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$614.06 |
| Max. Negotiated Rate |
$4,534.56 |
| Rate for Payer: Aetna Commercial |
$3,637.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,684.33
|
| Rate for Payer: Cash Price |
$2,361.75
|
| Rate for Payer: Cigna Commercial |
$3,920.50
|
| Rate for Payer: First Health Commercial |
$4,487.32
|
| Rate for Payer: Humana Commercial |
$4,014.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,873.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,485.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,417.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,156.68
|
| Rate for Payer: Ohio Health Group HMO |
$3,542.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$614.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,464.28
|
| Rate for Payer: PHCS Commercial |
$4,534.56
|
| Rate for Payer: United Healthcare All Payer |
$4,156.68
|
|
