|
OXIMETRY MULT DETERMINATION
|
Facility
|
OP
|
$301.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
46000017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem Medicaid |
$103.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Humana KY Medicaid |
$103.51
|
| Rate for Payer: Kentucky WC Medicaid |
$104.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$105.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.31
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
OXIMETRY MULT DETERMINATION
|
Facility
|
IP
|
$301.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
46000017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$288.96 |
| Rate for Payer: Aetna Commercial |
$231.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$234.78
|
| Rate for Payer: Cash Price |
$150.50
|
| Rate for Payer: Cigna Commercial |
$249.83
|
| Rate for Payer: First Health Commercial |
$285.95
|
| Rate for Payer: Humana Commercial |
$255.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$246.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$222.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$90.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$264.88
|
| Rate for Payer: Ohio Health Group HMO |
$225.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$60.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$39.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$93.31
|
| Rate for Payer: PHCS Commercial |
$288.96
|
| Rate for Payer: United Healthcare All Payer |
$264.88
|
|
|
OXIMETRY MULT DETERMINATION(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
460P0017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$9.62
|
| Rate for Payer: Anthem Medicaid |
$18.62
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$7.82
|
| Rate for Payer: Healthspan PPO |
$7.45
|
| Rate for Payer: Humana Medicaid |
$18.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.40
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$18.99
|
| Rate for Payer: Molina Healthcare Passport |
$18.62
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$18.81
|
|
|
OXIMETRY MULT DETERMINATION(T
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
460T0017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$26.13 |
| Max. Negotiated Rate |
$192.96 |
| Rate for Payer: Aetna Commercial |
$154.77
|
| Rate for Payer: Anthem Medicaid |
$69.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.78
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$166.83
|
| Rate for Payer: First Health Commercial |
$190.95
|
| Rate for Payer: Humana Commercial |
$170.85
|
| Rate for Payer: Humana KY Medicaid |
$69.12
|
| Rate for Payer: Kentucky WC Medicaid |
$69.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$70.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.88
|
| Rate for Payer: Ohio Health Group HMO |
$150.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.31
|
| Rate for Payer: PHCS Commercial |
$192.96
|
| Rate for Payer: United Healthcare All Payer |
$176.88
|
|
|
OXIMETRY MULT DETERMINATION(T
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
460T0017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$26.13 |
| Max. Negotiated Rate |
$192.96 |
| Rate for Payer: Aetna Commercial |
$154.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$156.78
|
| Rate for Payer: Cash Price |
$100.50
|
| Rate for Payer: Cigna Commercial |
$166.83
|
| Rate for Payer: First Health Commercial |
$190.95
|
| Rate for Payer: Humana Commercial |
$170.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$148.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.88
|
| Rate for Payer: Ohio Health Group HMO |
$150.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.31
|
| Rate for Payer: PHCS Commercial |
$192.96
|
| Rate for Payer: United Healthcare All Payer |
$176.88
|
|
|
OXINIUM FEM HD 12/14 26MM +0
|
Facility
|
IP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +0
|
Facility
|
OP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem Medicaid |
$3,863.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Humana KY Medicaid |
$3,863.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,902.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,940.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +12
|
Facility
|
IP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +12
|
Facility
|
OP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem Medicaid |
$3,863.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Humana KY Medicaid |
$3,863.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,902.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,940.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +4
|
Facility
|
IP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +4
|
Facility
|
OP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem Medicaid |
$3,863.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Humana KY Medicaid |
$3,863.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,902.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,940.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +8
|
Facility
|
IP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 26MM +8
|
Facility
|
OP
|
$11,233.09
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,460.30 |
| Max. Negotiated Rate |
$10,783.77 |
| Rate for Payer: Aetna Commercial |
$8,649.48
|
| Rate for Payer: Anthem Medicaid |
$3,863.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,761.81
|
| Rate for Payer: Cash Price |
$5,616.55
|
| Rate for Payer: Cigna Commercial |
$9,323.46
|
| Rate for Payer: First Health Commercial |
$10,671.44
|
| Rate for Payer: Humana Commercial |
$9,548.13
|
| Rate for Payer: Humana KY Medicaid |
$3,863.06
|
| Rate for Payer: Kentucky WC Medicaid |
$3,902.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,211.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,290.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,369.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,940.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,885.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,424.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,246.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,460.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,482.26
|
| Rate for Payer: PHCS Commercial |
$10,783.77
|
| Rate for Payer: United Healthcare All Payer |
$9,885.12
|
|
|
OXINIUM FEM HD 12/14 28MM +0
|
Facility
|
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +0
|
Facility
|
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem Medicaid |
$1,659.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Humana KY Medicaid |
$1,659.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +12
|
Facility
|
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem Medicaid |
$1,659.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Humana KY Medicaid |
$1,659.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +12
|
Facility
|
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +16
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
OXINIUM FEM HD 12/14 28MM +16
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
OXINIUM FEM HD 12/14 28MM -3
|
Facility
|
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem Medicaid |
$1,659.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Humana KY Medicaid |
$1,659.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM -3
|
Facility
|
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +4
|
Facility
|
IP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +4
|
Facility
|
OP
|
$4,825.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$627.25 |
| Max. Negotiated Rate |
$4,632.00 |
| Rate for Payer: Aetna Commercial |
$3,715.25
|
| Rate for Payer: Anthem Medicaid |
$1,659.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,763.50
|
| Rate for Payer: Cash Price |
$2,412.50
|
| Rate for Payer: Cigna Commercial |
$4,004.75
|
| Rate for Payer: First Health Commercial |
$4,583.75
|
| Rate for Payer: Humana Commercial |
$4,101.25
|
| Rate for Payer: Humana KY Medicaid |
$1,659.32
|
| Rate for Payer: Kentucky WC Medicaid |
$1,676.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,956.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,560.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,447.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,692.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,246.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,618.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$965.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$627.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,495.75
|
| Rate for Payer: PHCS Commercial |
$4,632.00
|
| Rate for Payer: United Healthcare All Payer |
$4,246.00
|
|
|
OXINIUM FEM HD 12/14 28MM +8
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
OXINIUM FEM HD 12/14 28MM +8
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
