|
REF I POR ACET SHELL 60OD
|
Facility
|
OP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Anthem Medicaid |
$3,937.75
|
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Humana KY Medicaid |
$3,937.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,977.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,016.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 62OD
|
Facility
|
IP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 62OD
|
Facility
|
OP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem Medicaid |
$3,937.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Humana KY Medicaid |
$3,937.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,977.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,016.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 64OD
|
Facility
|
IP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 64OD
|
Facility
|
OP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem Medicaid |
$3,937.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Humana KY Medicaid |
$3,937.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,977.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,016.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 66OD
|
Facility
|
IP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 66OD
|
Facility
|
OP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem Medicaid |
$3,937.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Humana KY Medicaid |
$3,937.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,977.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,016.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 68OD
|
Facility
|
IP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 68OD
|
Facility
|
OP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem Medicaid |
$3,937.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Humana KY Medicaid |
$3,937.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,977.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,016.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 70OD
|
Facility
|
OP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem Medicaid |
$3,937.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Humana KY Medicaid |
$3,937.75
|
| Rate for Payer: Kentucky WC Medicaid |
$3,977.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,016.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REF I POR ACET SHELL 70OD
|
Facility
|
IP
|
$11,450.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,488.54 |
| Max. Negotiated Rate |
$10,992.26 |
| Rate for Payer: Aetna Commercial |
$8,816.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,931.21
|
| Rate for Payer: Cash Price |
$5,725.13
|
| Rate for Payer: Cigna Commercial |
$9,503.72
|
| Rate for Payer: First Health Commercial |
$10,877.76
|
| Rate for Payer: Humana Commercial |
$9,732.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,389.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,450.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,435.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,076.24
|
| Rate for Payer: Ohio Health Group HMO |
$8,587.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,290.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,488.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,549.58
|
| Rate for Payer: PHCS Commercial |
$10,992.26
|
| Rate for Payer: United Healthcare All Payer |
$10,076.24
|
|
|
REFL 3 HOLE SCRATCH MM 50
|
Facility
|
IP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 50
|
Facility
|
OP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem Medicaid |
$3,668.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Humana KY Medicaid |
$3,668.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,706.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,742.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 52
|
Facility
|
IP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 52
|
Facility
|
OP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem Medicaid |
$3,668.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Humana KY Medicaid |
$3,668.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,706.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,742.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 56
|
Facility
|
OP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem Medicaid |
$3,668.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Humana KY Medicaid |
$3,668.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,706.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,742.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 56
|
Facility
|
IP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 58
|
Facility
|
IP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 58
|
Facility
|
OP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem Medicaid |
$3,668.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Humana KY Medicaid |
$3,668.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,706.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,742.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 60
|
Facility
|
IP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REFL 3 HOLE SCRATCH MM 60
|
Facility
|
OP
|
$10,668.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,386.90 |
| Max. Negotiated Rate |
$10,241.70 |
| Rate for Payer: Aetna Commercial |
$8,214.70
|
| Rate for Payer: Anthem Medicaid |
$3,668.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,321.38
|
| Rate for Payer: Cash Price |
$5,334.22
|
| Rate for Payer: Cigna Commercial |
$8,854.81
|
| Rate for Payer: First Health Commercial |
$10,135.02
|
| Rate for Payer: Humana Commercial |
$9,068.17
|
| Rate for Payer: Humana KY Medicaid |
$3,668.88
|
| Rate for Payer: Kentucky WC Medicaid |
$3,706.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,748.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,873.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,200.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,742.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,388.23
|
| Rate for Payer: Ohio Health Group HMO |
$8,001.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,133.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,386.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,307.22
|
| Rate for Payer: PHCS Commercial |
$10,241.70
|
| Rate for Payer: United Healthcare All Payer |
$9,388.23
|
|
|
REF LAB MISC SERVICE
|
Facility
|
OP
|
$340.00
|
|
| Hospital Charge Code |
30001565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem Medicaid |
$116.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.02
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Humana KY Medicaid |
$116.93
|
| Rate for Payer: Kentucky WC Medicaid |
$118.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$119.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.40
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
REF LAB MISC SERVICE
|
Facility
|
IP
|
$340.00
|
|
| Hospital Charge Code |
30001565
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$326.40 |
| Rate for Payer: Aetna Commercial |
$261.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$273.02
|
| Rate for Payer: Cash Price |
$170.00
|
| Rate for Payer: Cigna Commercial |
$282.20
|
| Rate for Payer: First Health Commercial |
$323.00
|
| Rate for Payer: Humana Commercial |
$289.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$278.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$250.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$102.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$299.20
|
| Rate for Payer: Ohio Health Group HMO |
$255.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$68.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$44.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$105.40
|
| Rate for Payer: PHCS Commercial |
$326.40
|
| Rate for Payer: United Healthcare All Payer |
$299.20
|
|
|
REFLECTIN ACE LINER28ID*46-48
|
Facility
|
IP
|
$8,885.46
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.11 |
| Max. Negotiated Rate |
$8,530.04 |
| Rate for Payer: Aetna Commercial |
$6,841.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,930.66
|
| Rate for Payer: Cash Price |
$4,442.73
|
| Rate for Payer: Cigna Commercial |
$7,374.93
|
| Rate for Payer: First Health Commercial |
$8,441.19
|
| Rate for Payer: Humana Commercial |
$7,552.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,286.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,557.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,665.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,819.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,664.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,777.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,155.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,754.49
|
| Rate for Payer: PHCS Commercial |
$8,530.04
|
| Rate for Payer: United Healthcare All Payer |
$7,819.20
|
|
|
REFLECTIN ACE LINER28ID*46-48
|
Facility
|
OP
|
$8,885.46
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,155.11 |
| Max. Negotiated Rate |
$8,530.04 |
| Rate for Payer: Aetna Commercial |
$6,841.80
|
| Rate for Payer: Anthem Medicaid |
$3,055.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,930.66
|
| Rate for Payer: Cash Price |
$4,442.73
|
| Rate for Payer: Cigna Commercial |
$7,374.93
|
| Rate for Payer: First Health Commercial |
$8,441.19
|
| Rate for Payer: Humana Commercial |
$7,552.64
|
| Rate for Payer: Humana KY Medicaid |
$3,055.71
|
| Rate for Payer: Kentucky WC Medicaid |
$3,086.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,286.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,557.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,665.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,117.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,819.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,664.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,777.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,155.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,754.49
|
| Rate for Payer: PHCS Commercial |
$8,530.04
|
| Rate for Payer: United Healthcare All Payer |
$7,819.20
|
|
