|
RESTYLANE SILK
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200027
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$600.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Multiplan PHCS |
$360.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$420.00
|
| Rate for Payer: UHCCP Medicaid |
$210.00
|
|
|
RESURF PAT W/JRNY PEG 26MM
|
Facility
|
OP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem Medicaid |
$2,272.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Humana KY Medicaid |
$2,272.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,295.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,318.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 26MM
|
Facility
|
IP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 29MM
|
Facility
|
OP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem Medicaid |
$2,272.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Humana KY Medicaid |
$2,272.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,295.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,318.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 29MM
|
Facility
|
IP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 32MM
|
Facility
|
OP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem Medicaid |
$2,272.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Humana KY Medicaid |
$2,272.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,295.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,318.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 32MM
|
Facility
|
IP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 35MM
|
Facility
|
IP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 35MM
|
Facility
|
OP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem Medicaid |
$2,272.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Humana KY Medicaid |
$2,272.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,295.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,318.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 38MM
|
Facility
|
IP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 38MM
|
Facility
|
OP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem Medicaid |
$2,272.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Humana KY Medicaid |
$2,272.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,295.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,318.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 41MM
|
Facility
|
IP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF PAT W/JRNY PEG 41MM
|
Facility
|
OP
|
$6,607.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$859.02 |
| Max. Negotiated Rate |
$6,343.55 |
| Rate for Payer: Aetna Commercial |
$5,088.05
|
| Rate for Payer: Anthem Medicaid |
$2,272.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,154.13
|
| Rate for Payer: Cash Price |
$3,303.93
|
| Rate for Payer: Cigna Commercial |
$5,484.52
|
| Rate for Payer: First Health Commercial |
$6,277.47
|
| Rate for Payer: Humana Commercial |
$5,616.68
|
| Rate for Payer: Humana KY Medicaid |
$2,272.44
|
| Rate for Payer: Kentucky WC Medicaid |
$2,295.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,418.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,876.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,982.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,318.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,814.92
|
| Rate for Payer: Ohio Health Group HMO |
$4,955.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,321.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$859.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,048.44
|
| Rate for Payer: PHCS Commercial |
$6,343.55
|
| Rate for Payer: United Healthcare All Payer |
$5,814.92
|
|
|
RESURF W/JRNY ELIP PAT PEG 29
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 29
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem Medicaid |
$1,177.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Humana KY Medicaid |
$1,177.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 32
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 32
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem Medicaid |
$1,177.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Humana KY Medicaid |
$1,177.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 35
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 35
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem Medicaid |
$1,177.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Humana KY Medicaid |
$1,177.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 38
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem Medicaid |
$1,177.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Humana KY Medicaid |
$1,177.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 38
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 41
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem Medicaid |
$1,177.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Humana KY Medicaid |
$1,177.86
|
| Rate for Payer: Kentucky WC Medicaid |
$1,189.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,201.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 41
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$445.25 |
| Max. Negotiated Rate |
$3,288.00 |
| Rate for Payer: Aetna Commercial |
$2,637.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,671.50
|
| Rate for Payer: Cash Price |
$1,712.50
|
| Rate for Payer: Cigna Commercial |
$2,842.75
|
| Rate for Payer: First Health Commercial |
$3,253.75
|
| Rate for Payer: Humana Commercial |
$2,911.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,808.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,527.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,027.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,014.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,568.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,061.75
|
| Rate for Payer: PHCS Commercial |
$3,288.00
|
| Rate for Payer: United Healthcare All Payer |
$3,014.00
|
|
|
RESUR PAT GEN 11 7.5MM 26MM
|
Facility
|
IP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
|
RESUR PAT GEN 11 7.5MM 26MM
|
Facility
|
OP
|
$3,250.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$422.50 |
| Max. Negotiated Rate |
$3,120.00 |
| Rate for Payer: Aetna Commercial |
$2,502.50
|
| Rate for Payer: Anthem Medicaid |
$1,117.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,535.00
|
| Rate for Payer: Cash Price |
$1,625.00
|
| Rate for Payer: Cigna Commercial |
$2,697.50
|
| Rate for Payer: First Health Commercial |
$3,087.50
|
| Rate for Payer: Humana Commercial |
$2,762.50
|
| Rate for Payer: Humana KY Medicaid |
$1,117.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,129.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,665.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$975.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,140.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,860.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,437.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$422.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,007.50
|
| Rate for Payer: PHCS Commercial |
$3,120.00
|
| Rate for Payer: United Healthcare All Payer |
$2,860.00
|
|
