|
REF NH HA SHELL SZ 56MM
|
Facility
|
IP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 56MM
|
Facility
|
OP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem Medicaid |
$4,042.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Humana KY Medicaid |
$4,042.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,123.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 58MM
|
Facility
|
IP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 58MM
|
Facility
|
OP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem Medicaid |
$4,042.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Humana KY Medicaid |
$4,042.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,123.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 60MM
|
Facility
|
IP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 60MM
|
Facility
|
OP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem Medicaid |
$4,042.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Humana KY Medicaid |
$4,042.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,123.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 62MM
|
Facility
|
IP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 62MM
|
Facility
|
OP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem Medicaid |
$4,042.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Humana KY Medicaid |
$4,042.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,123.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 64MM
|
Facility
|
OP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem Medicaid |
$4,042.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Humana KY Medicaid |
$4,042.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,083.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,123.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NH HA SHELL SZ 64MM
|
Facility
|
IP
|
$11,753.83
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,526.15 |
| Max. Negotiated Rate |
$11,283.68 |
| Rate for Payer: Aetna Commercial |
$9,050.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,167.99
|
| Rate for Payer: Cash Price |
$5,876.92
|
| Rate for Payer: Cigna Commercial |
$9,755.68
|
| Rate for Payer: First Health Commercial |
$11,166.14
|
| Rate for Payer: Humana Commercial |
$9,990.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,638.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,674.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,526.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,343.37
|
| Rate for Payer: Ohio Health Group HMO |
$8,815.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,403.06
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,225.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,110.14
|
| Rate for Payer: PHCS Commercial |
$11,283.68
|
| Rate for Payer: United Healthcare All Payer |
$10,343.37
|
|
|
REF NO HOLE SHELL 46MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 46MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 48MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 48MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 50MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 50MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 52MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 52MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 54MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 54MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 56MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 56MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 58MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 58MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 60MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
