|
REFL PERIPHERAL HOLE 76MM HA
|
Facility
|
IP
|
$12,496.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$11,996.77 |
| Rate for Payer: Aetna Commercial |
$9,622.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,747.38
|
| Rate for Payer: Cash Price |
$6,248.32
|
| Rate for Payer: Cigna Commercial |
$10,372.21
|
| Rate for Payer: First Health Commercial |
$11,871.81
|
| Rate for Payer: Humana Commercial |
$10,622.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,247.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,222.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,748.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,997.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,372.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,997.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,872.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,622.68
|
| Rate for Payer: PHCS Commercial |
$11,996.77
|
| Rate for Payer: United Healthcare All Payer |
$10,997.04
|
|
|
REFL PERIPHERAL HOLE 76MM HA
|
Facility
|
OP
|
$12,496.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$11,996.77 |
| Rate for Payer: Aetna Commercial |
$9,622.41
|
| Rate for Payer: Anthem Medicaid |
$4,297.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,747.38
|
| Rate for Payer: Cash Price |
$6,248.32
|
| Rate for Payer: Cigna Commercial |
$10,372.21
|
| Rate for Payer: First Health Commercial |
$11,871.81
|
| Rate for Payer: Humana Commercial |
$10,622.14
|
| Rate for Payer: Humana KY Medicaid |
$4,297.59
|
| Rate for Payer: Kentucky WC Medicaid |
$4,341.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,247.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,222.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,748.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,383.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,997.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,372.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,997.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,872.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,622.68
|
| Rate for Payer: PHCS Commercial |
$11,996.77
|
| Rate for Payer: United Healthcare All Payer |
$10,997.04
|
|
|
REFL PERIPHERAL HOLE 78MM HA
|
Facility
|
IP
|
$12,496.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$11,996.77 |
| Rate for Payer: Aetna Commercial |
$9,622.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,747.38
|
| Rate for Payer: Cash Price |
$6,248.32
|
| Rate for Payer: Cigna Commercial |
$10,372.21
|
| Rate for Payer: First Health Commercial |
$11,871.81
|
| Rate for Payer: Humana Commercial |
$10,622.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,247.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,222.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,748.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,997.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,372.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,997.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,872.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,622.68
|
| Rate for Payer: PHCS Commercial |
$11,996.77
|
| Rate for Payer: United Healthcare All Payer |
$10,997.04
|
|
|
REFL PERIPHERAL HOLE 78MM HA
|
Facility
|
OP
|
$12,496.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$11,996.77 |
| Rate for Payer: Aetna Commercial |
$9,622.41
|
| Rate for Payer: Anthem Medicaid |
$4,297.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,747.38
|
| Rate for Payer: Cash Price |
$6,248.32
|
| Rate for Payer: Cigna Commercial |
$10,372.21
|
| Rate for Payer: First Health Commercial |
$11,871.81
|
| Rate for Payer: Humana Commercial |
$10,622.14
|
| Rate for Payer: Humana KY Medicaid |
$4,297.59
|
| Rate for Payer: Kentucky WC Medicaid |
$4,341.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,247.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,222.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,748.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,383.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,997.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,372.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,997.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,872.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,622.68
|
| Rate for Payer: PHCS Commercial |
$11,996.77
|
| Rate for Payer: United Healthcare All Payer |
$10,997.04
|
|
|
REFL PERIPHERAL HOLE 80MM HA
|
Facility
|
OP
|
$12,496.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$11,996.77 |
| Rate for Payer: Aetna Commercial |
$9,622.41
|
| Rate for Payer: Anthem Medicaid |
$4,297.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,747.38
|
| Rate for Payer: Cash Price |
$6,248.32
|
| Rate for Payer: Cigna Commercial |
$10,372.21
|
| Rate for Payer: First Health Commercial |
$11,871.81
|
| Rate for Payer: Humana Commercial |
$10,622.14
|
| Rate for Payer: Humana KY Medicaid |
$4,297.59
|
| Rate for Payer: Kentucky WC Medicaid |
$4,341.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,247.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,222.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,748.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,383.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,997.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,372.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,997.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,872.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,622.68
|
| Rate for Payer: PHCS Commercial |
$11,996.77
|
| Rate for Payer: United Healthcare All Payer |
$10,997.04
|
|
|
REFL PERIPHERAL HOLE 80MM HA
|
Facility
|
IP
|
$12,496.64
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,748.99 |
| Max. Negotiated Rate |
$11,996.77 |
| Rate for Payer: Aetna Commercial |
$9,622.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,747.38
|
| Rate for Payer: Cash Price |
$6,248.32
|
| Rate for Payer: Cigna Commercial |
$10,372.21
|
| Rate for Payer: First Health Commercial |
$11,871.81
|
| Rate for Payer: Humana Commercial |
$10,622.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,247.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,222.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,748.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,997.04
|
| Rate for Payer: Ohio Health Group HMO |
$9,372.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,997.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,872.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,622.68
|
| Rate for Payer: PHCS Commercial |
$11,996.77
|
| Rate for Payer: United Healthcare All Payer |
$10,997.04
|
|
|
REFL XLPE 28 20 +4 46-48
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 28 20 +4 46-48
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 28 20 +4 50-52
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 28 20 +4 50-52
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 28 20 +4 54-56
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 28 20 +4 54-56
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 54-56
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 54-56
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 58-60
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 58-60
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 62-64
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 62-64
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 66-68
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 66-68
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 70-76
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 32 20 +4 70-76
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 35 28 46-48
|
Facility
|
OP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem Medicaid |
$3,030.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Humana KY Medicaid |
$3,030.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3,060.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,090.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 35 28 46-48
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
|
REFL XLPE 35 28 50-52
|
Facility
|
IP
|
$8,810.98
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,643.29 |
| Max. Negotiated Rate |
$8,458.54 |
| Rate for Payer: Aetna Commercial |
$6,784.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,872.56
|
| Rate for Payer: Cash Price |
$4,405.49
|
| Rate for Payer: Cigna Commercial |
$7,313.11
|
| Rate for Payer: First Health Commercial |
$8,370.43
|
| Rate for Payer: Humana Commercial |
$7,489.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,225.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,502.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,643.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,753.66
|
| Rate for Payer: Ohio Health Group HMO |
$6,608.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,048.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,665.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,079.58
|
| Rate for Payer: PHCS Commercial |
$8,458.54
|
| Rate for Payer: United Healthcare All Payer |
$7,753.66
|
|
