|
OXIMETRY MULT DETERMINATION(T
|
Facility
|
IP
|
$208.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
460T0017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$62.40 |
| Max. Negotiated Rate |
$199.68 |
| Rate for Payer: Aetna Commercial |
$160.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$162.24
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Cigna Commercial |
$172.64
|
| Rate for Payer: First Health Commercial |
$197.60
|
| Rate for Payer: Humana Commercial |
$176.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$170.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$153.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$183.04
|
| Rate for Payer: Ohio Health Group HMO |
$156.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$166.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$143.52
|
| Rate for Payer: PHCS Commercial |
$199.68
|
| Rate for Payer: United Healthcare All Payer |
$183.04
|
|
|
OXIMETRY MULT DETERMINATION(T
|
Facility
|
OP
|
$208.00
|
|
|
Service Code
|
HCPCS 94761
|
| Hospital Charge Code |
460T0017
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$62.40 |
| Max. Negotiated Rate |
$199.68 |
| Rate for Payer: Aetna Commercial |
$160.16
|
| Rate for Payer: Anthem Medicaid |
$71.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$162.24
|
| Rate for Payer: Cash Price |
$104.00
|
| Rate for Payer: Cigna Commercial |
$172.64
|
| Rate for Payer: First Health Commercial |
$197.60
|
| Rate for Payer: Humana Commercial |
$176.80
|
| Rate for Payer: Humana KY Medicaid |
$71.53
|
| Rate for Payer: Kentucky WC Medicaid |
$72.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$170.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$153.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$62.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$72.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$183.04
|
| Rate for Payer: Ohio Health Group HMO |
$156.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$166.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.96
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$143.52
|
| Rate for Payer: PHCS Commercial |
$199.68
|
| Rate for Payer: United Healthcare All Payer |
$183.04
|
|
|
OXINIUM FEM HD 12/14 26MM +0
|
Facility
|
OP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem Medicaid |
$3,946.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Humana KY Medicaid |
$3,946.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,986.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,025.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +0
|
Facility
|
IP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +12
|
Facility
|
OP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem Medicaid |
$3,946.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Humana KY Medicaid |
$3,946.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,986.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,025.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +12
|
Facility
|
IP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +4
|
Facility
|
OP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem Medicaid |
$3,946.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Humana KY Medicaid |
$3,946.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,986.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,025.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +4
|
Facility
|
IP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +8
|
Facility
|
OP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem Medicaid |
$3,946.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Humana KY Medicaid |
$3,946.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,986.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,025.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 26MM +8
|
Facility
|
IP
|
$11,476.56
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,442.97 |
| Max. Negotiated Rate |
$11,017.50 |
| Rate for Payer: Aetna Commercial |
$8,836.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,951.72
|
| Rate for Payer: Cash Price |
$5,738.28
|
| Rate for Payer: Cigna Commercial |
$9,525.54
|
| Rate for Payer: First Health Commercial |
$10,902.73
|
| Rate for Payer: Humana Commercial |
$9,755.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,410.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,469.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,442.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,099.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,607.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,181.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,984.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,918.83
|
| Rate for Payer: PHCS Commercial |
$11,017.50
|
| Rate for Payer: United Healthcare All Payer |
$10,099.37
|
|
|
OXINIUM FEM HD 12/14 28MM +0
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +0
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +12
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +12
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +16
|
Facility
|
IP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
OXINIUM FEM HD 12/14 28MM +16
|
Facility
|
OP
|
$5,187.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,556.25 |
| Max. Negotiated Rate |
$4,980.00 |
| Rate for Payer: Aetna Commercial |
$3,994.38
|
| Rate for Payer: Anthem Medicaid |
$1,783.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,046.25
|
| Rate for Payer: Cash Price |
$2,593.75
|
| Rate for Payer: Cigna Commercial |
$4,305.62
|
| Rate for Payer: First Health Commercial |
$4,928.12
|
| Rate for Payer: Humana Commercial |
$4,409.38
|
| Rate for Payer: Humana KY Medicaid |
$1,783.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,802.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,253.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,828.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,556.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,819.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,565.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,890.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,150.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,513.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,579.38
|
| Rate for Payer: PHCS Commercial |
$4,980.00
|
| Rate for Payer: United Healthcare All Payer |
$4,565.00
|
|
|
OXINIUM FEM HD 12/14 28MM -3
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM -3
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +4
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +4
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +8
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 28MM +8
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 32MM +0
|
Facility
|
OP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem Medicaid |
$1,655.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Humana KY Medicaid |
$1,655.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,671.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,688.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 32MM +0
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
|
OXINIUM FEM HD 12/14 32MM +12
|
Facility
|
IP
|
$4,812.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,443.75 |
| Max. Negotiated Rate |
$4,620.00 |
| Rate for Payer: Aetna Commercial |
$3,705.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,753.75
|
| Rate for Payer: Cash Price |
$2,406.25
|
| Rate for Payer: Cigna Commercial |
$3,994.38
|
| Rate for Payer: First Health Commercial |
$4,571.88
|
| Rate for Payer: Humana Commercial |
$4,090.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,946.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,551.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,443.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,235.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,609.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,850.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,186.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,320.62
|
| Rate for Payer: PHCS Commercial |
$4,620.00
|
| Rate for Payer: United Healthcare All Payer |
$4,235.00
|
|
