|
RFB EMBEDDED EYELID
|
Facility
|
OP
|
$417.00
|
|
|
Service Code
|
HCPCS 67938
|
| Hospital Charge Code |
76102398
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$54.21 |
| Max. Negotiated Rate |
$400.32 |
| Rate for Payer: Aetna Commercial |
$321.09
|
| Rate for Payer: Anthem Medicaid |
$143.41
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$251.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$325.26
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$352.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$340.08
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cash Price |
$208.50
|
| Rate for Payer: Cigna Commercial |
$346.11
|
| Rate for Payer: First Health Commercial |
$396.15
|
| Rate for Payer: Humana Commercial |
$354.45
|
| Rate for Payer: Humana KY Medicaid |
$143.41
|
| Rate for Payer: Humana Medicare Advantage |
$251.91
|
| Rate for Payer: Kentucky WC Medicaid |
$144.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$341.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$307.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$302.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$146.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$366.96
|
| Rate for Payer: Ohio Health Group HMO |
$312.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$83.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$54.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$129.27
|
| Rate for Payer: PHCS Commercial |
$400.32
|
| Rate for Payer: United Healthcare All Payer |
$366.96
|
|
|
RFB EMBEDDED EYELID
|
Facility
|
OP
|
$435.00
|
|
|
Service Code
|
HCPCS 67938
|
| Hospital Charge Code |
45000304
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna Commercial |
$334.95
|
| Rate for Payer: Anthem Medicaid |
$149.60
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$251.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$339.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$352.67
|
| Rate for Payer: CareSource Just4Me Medicare |
$340.08
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$361.05
|
| Rate for Payer: First Health Commercial |
$413.25
|
| Rate for Payer: Humana Commercial |
$369.75
|
| Rate for Payer: Humana KY Medicaid |
$149.60
|
| Rate for Payer: Humana Medicare Advantage |
$251.91
|
| Rate for Payer: Kentucky WC Medicaid |
$151.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$302.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$152.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$382.80
|
| Rate for Payer: Ohio Health Group HMO |
$326.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$134.85
|
| Rate for Payer: PHCS Commercial |
$417.60
|
| Rate for Payer: United Healthcare All Payer |
$382.80
|
|
|
RFB EMBEDDED EYELID
|
Facility
|
IP
|
$435.00
|
|
|
Service Code
|
HCPCS 67938
|
| Hospital Charge Code |
45000304
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$417.60 |
| Rate for Payer: Aetna Commercial |
$334.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$339.30
|
| Rate for Payer: Cash Price |
$217.50
|
| Rate for Payer: Cigna Commercial |
$361.05
|
| Rate for Payer: First Health Commercial |
$413.25
|
| Rate for Payer: Humana Commercial |
$369.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$356.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$321.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$130.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$382.80
|
| Rate for Payer: Ohio Health Group HMO |
$326.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$87.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$56.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$134.85
|
| Rate for Payer: PHCS Commercial |
$417.60
|
| Rate for Payer: United Healthcare All Payer |
$382.80
|
|
|
RFB EXTRN EYECORNEA W SLITLAMP
|
Facility
|
IP
|
$335.00
|
|
|
Service Code
|
HCPCS 65222
|
| Hospital Charge Code |
76102384
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.85
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
RFB EXTRN EYECORNEA W SLITLAMP
|
Facility
|
OP
|
$335.00
|
|
|
Service Code
|
HCPCS 65222
|
| Hospital Charge Code |
76102384
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$43.55 |
| Max. Negotiated Rate |
$321.60 |
| Rate for Payer: Aetna Commercial |
$257.95
|
| Rate for Payer: Anthem Medicaid |
$115.21
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$261.30
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cash Price |
$167.50
|
| Rate for Payer: Cigna Commercial |
$278.05
|
| Rate for Payer: First Health Commercial |
$318.25
|
| Rate for Payer: Humana Commercial |
$284.75
|
| Rate for Payer: Humana KY Medicaid |
$115.21
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$116.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$274.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$247.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$117.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$294.80
|
| Rate for Payer: Ohio Health Group HMO |
$251.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$67.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$43.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$103.85
|
| Rate for Payer: PHCS Commercial |
$321.60
|
| Rate for Payer: United Healthcare All Payer |
$294.80
|
|
|
RFB EXTRN EYECORNEA W SLITLAMP
|
Facility
|
IP
|
$364.00
|
|
|
Service Code
|
HCPCS 65222
|
| Hospital Charge Code |
45000300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$47.32 |
| Max. Negotiated Rate |
$349.44 |
| Rate for Payer: Aetna Commercial |
$280.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$283.92
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cigna Commercial |
$302.12
|
| Rate for Payer: First Health Commercial |
$345.80
|
| Rate for Payer: Humana Commercial |
$309.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$298.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$268.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$109.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$320.32
|
| Rate for Payer: Ohio Health Group HMO |
$273.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.84
|
| Rate for Payer: PHCS Commercial |
$349.44
|
| Rate for Payer: United Healthcare All Payer |
$320.32
|
|
|
RFB EXTRN EYECORNEA W SLITLAMP
|
Facility
|
OP
|
$364.00
|
|
|
Service Code
|
HCPCS 65222
|
| Hospital Charge Code |
45000300
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$47.32 |
| Max. Negotiated Rate |
$349.44 |
| Rate for Payer: Aetna Commercial |
$280.28
|
| Rate for Payer: Anthem Medicaid |
$125.18
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$110.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$283.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$154.64
|
| Rate for Payer: CareSource Just4Me Medicare |
$149.12
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: Cigna Commercial |
$302.12
|
| Rate for Payer: First Health Commercial |
$345.80
|
| Rate for Payer: Humana Commercial |
$309.40
|
| Rate for Payer: Humana KY Medicaid |
$125.18
|
| Rate for Payer: Humana Medicare Advantage |
$110.46
|
| Rate for Payer: Kentucky WC Medicaid |
$126.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$298.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$268.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$132.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$127.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$320.32
|
| Rate for Payer: Ohio Health Group HMO |
$273.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$72.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$47.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$112.84
|
| Rate for Payer: PHCS Commercial |
$349.44
|
| Rate for Payer: United Healthcare All Payer |
$320.32
|
|
|
RFB INTRAOCUL ANTIORCHMBR LENS
|
Facility
|
IP
|
$2,896.00
|
|
|
Service Code
|
HCPCS 65235
|
| Hospital Charge Code |
76102385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.48 |
| Max. Negotiated Rate |
$2,780.16 |
| Rate for Payer: Aetna Commercial |
$2,229.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,258.88
|
| Rate for Payer: Cash Price |
$1,448.00
|
| Rate for Payer: Cigna Commercial |
$2,403.68
|
| Rate for Payer: First Health Commercial |
$2,751.20
|
| Rate for Payer: Humana Commercial |
$2,461.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,374.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,137.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$868.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,548.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,172.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$579.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.76
|
| Rate for Payer: PHCS Commercial |
$2,780.16
|
| Rate for Payer: United Healthcare All Payer |
$2,548.48
|
|
|
RFB INTRAOCUL ANTIORCHMBR LENS
|
Facility
|
OP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 65235
|
| Hospital Charge Code |
45000301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$392.60 |
| Max. Negotiated Rate |
$2,899.20 |
| Rate for Payer: Aetna Commercial |
$2,325.40
|
| Rate for Payer: Anthem Medicaid |
$1,038.58
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,015.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,355.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,821.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,720.51
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$2,506.60
|
| Rate for Payer: First Health Commercial |
$2,869.00
|
| Rate for Payer: Humana Commercial |
$2,567.00
|
| Rate for Payer: Humana KY Medicaid |
$1,038.58
|
| Rate for Payer: Humana Medicare Advantage |
$2,015.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,049.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,476.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,228.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,418.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,059.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,657.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,265.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$392.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.20
|
| Rate for Payer: PHCS Commercial |
$2,899.20
|
| Rate for Payer: United Healthcare All Payer |
$2,657.60
|
|
|
RFB INTRAOCUL ANTIORCHMBR LENS
|
Facility
|
IP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 65235
|
| Hospital Charge Code |
45000301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$392.60 |
| Max. Negotiated Rate |
$2,899.20 |
| Rate for Payer: Aetna Commercial |
$2,325.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,355.60
|
| Rate for Payer: Cash Price |
$1,510.00
|
| Rate for Payer: Cigna Commercial |
$2,506.60
|
| Rate for Payer: First Health Commercial |
$2,869.00
|
| Rate for Payer: Humana Commercial |
$2,567.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,476.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,228.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$906.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,657.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,265.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$604.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$392.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$936.20
|
| Rate for Payer: PHCS Commercial |
$2,899.20
|
| Rate for Payer: United Healthcare All Payer |
$2,657.60
|
|
|
RFB INTRAOCUL ANTIORCHMBR LENS
|
Facility
|
OP
|
$2,896.00
|
|
|
Service Code
|
HCPCS 65235
|
| Hospital Charge Code |
76102385
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$376.48 |
| Max. Negotiated Rate |
$2,821.27 |
| Rate for Payer: Aetna Commercial |
$2,229.92
|
| Rate for Payer: Anthem Medicaid |
$995.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,015.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,258.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,821.27
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,720.51
|
| Rate for Payer: Cash Price |
$1,448.00
|
| Rate for Payer: Cash Price |
$1,448.00
|
| Rate for Payer: Cigna Commercial |
$2,403.68
|
| Rate for Payer: First Health Commercial |
$2,751.20
|
| Rate for Payer: Humana Commercial |
$2,461.60
|
| Rate for Payer: Humana KY Medicaid |
$995.93
|
| Rate for Payer: Humana Medicare Advantage |
$2,015.19
|
| Rate for Payer: Kentucky WC Medicaid |
$1,006.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,374.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,137.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,418.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,015.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,548.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,172.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$579.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$376.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$897.76
|
| Rate for Payer: PHCS Commercial |
$2,780.16
|
| Rate for Payer: United Healthcare All Payer |
$2,548.48
|
|
|
RF FSO 5 POR HA ACET 42MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 42MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 46MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 46MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 48MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 48MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 50MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 50MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 52MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 52MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 54MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 54MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 56MM
|
Facility
|
IP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
|
RF FSO 5 POR HA ACET 56MM
|
Facility
|
OP
|
$11,167.94
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,451.83 |
| Max. Negotiated Rate |
$10,721.22 |
| Rate for Payer: Aetna Commercial |
$8,599.31
|
| Rate for Payer: Anthem Medicaid |
$3,840.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,710.99
|
| Rate for Payer: Cash Price |
$5,583.97
|
| Rate for Payer: Cigna Commercial |
$9,269.39
|
| Rate for Payer: First Health Commercial |
$10,609.54
|
| Rate for Payer: Humana Commercial |
$9,492.75
|
| Rate for Payer: Humana KY Medicaid |
$3,840.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,879.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,157.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,241.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,350.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,917.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,827.79
|
| Rate for Payer: Ohio Health Group HMO |
$8,375.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,233.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,451.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,462.06
|
| Rate for Payer: PHCS Commercial |
$10,721.22
|
| Rate for Payer: United Healthcare All Payer |
$9,827.79
|
|
