|
RESPOSIT. GASTRIC FEEDING TUBE
|
Facility
|
OP
|
$1,346.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
761T1792
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$224.72 |
| Max. Negotiated Rate |
$1,292.16 |
| Rate for Payer: Aetna Commercial |
$1,036.42
|
| Rate for Payer: Anthem Medicaid |
$462.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$224.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,049.88
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$314.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$303.37
|
| Rate for Payer: Cash Price |
$673.00
|
| Rate for Payer: Cash Price |
$673.00
|
| Rate for Payer: Cigna Commercial |
$1,117.18
|
| Rate for Payer: First Health Commercial |
$1,278.70
|
| Rate for Payer: Humana Commercial |
$1,144.10
|
| Rate for Payer: Humana KY Medicaid |
$462.89
|
| Rate for Payer: Humana Medicare Advantage |
$224.72
|
| Rate for Payer: Kentucky WC Medicaid |
$467.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,103.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$993.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$269.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$472.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,184.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,009.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,076.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,171.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$928.74
|
| Rate for Payer: PHCS Commercial |
$1,292.16
|
| Rate for Payer: United Healthcare All Payer |
$1,184.48
|
|
|
RESPOSIT. GASTRIC FEEDING TUBE
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
761P1792
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.44 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna Commercial |
$165.44
|
| Rate for Payer: Ambetter Exchange |
$97.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.44
|
| Rate for Payer: Anthem Medicaid |
$93.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$97.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$97.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$117.47
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cash Price |
$150.00
|
| Rate for Payer: Cigna Commercial |
$149.51
|
| Rate for Payer: Healthspan PPO |
$156.67
|
| Rate for Payer: Humana Medicaid |
$93.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$136.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$97.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.36
|
| Rate for Payer: Molina Healthcare Passport |
$93.49
|
| Rate for Payer: Multiplan PHCS |
$180.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$127.26
|
| Rate for Payer: UHCCP Medicaid |
$86.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$97.89
|
|
|
RESPOSIT. GASTRIC FEEDING TUBE
|
Professional
|
Both
|
$1,646.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
76101792
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$82.44 |
| Max. Negotiated Rate |
$987.60 |
| Rate for Payer: Aetna Commercial |
$165.44
|
| Rate for Payer: Ambetter Exchange |
$97.89
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$82.44
|
| Rate for Payer: Anthem Medicaid |
$93.49
|
| Rate for Payer: Buckeye Individual/Medicaid |
$97.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$97.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$117.47
|
| Rate for Payer: Cash Price |
$823.00
|
| Rate for Payer: Cash Price |
$823.00
|
| Rate for Payer: Cigna Commercial |
$149.51
|
| Rate for Payer: Healthspan PPO |
$156.67
|
| Rate for Payer: Humana Medicaid |
$93.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$136.21
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$97.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.89
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$95.36
|
| Rate for Payer: Molina Healthcare Passport |
$93.49
|
| Rate for Payer: Multiplan PHCS |
$987.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$127.26
|
| Rate for Payer: UHCCP Medicaid |
$86.56
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$94.42
|
| Rate for Payer: Wellcare Medicare Advantage |
$97.89
|
|
|
RESPOSIT. GASTRIC FEEDING TUBE
|
Facility
|
IP
|
$1,346.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
761T1792
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$403.80 |
| Max. Negotiated Rate |
$1,292.16 |
| Rate for Payer: Aetna Commercial |
$1,036.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,049.88
|
| Rate for Payer: Cash Price |
$673.00
|
| Rate for Payer: Cigna Commercial |
$1,117.18
|
| Rate for Payer: First Health Commercial |
$1,278.70
|
| Rate for Payer: Humana Commercial |
$1,144.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,103.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$993.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$403.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,184.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,009.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,076.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,171.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$928.74
|
| Rate for Payer: PHCS Commercial |
$1,292.16
|
| Rate for Payer: United Healthcare All Payer |
$1,184.48
|
|
|
RESPOSIT. GASTRIC FEEDING TUBE
|
Facility
|
IP
|
$1,646.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
76101792
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$493.80 |
| Max. Negotiated Rate |
$1,580.16 |
| Rate for Payer: Aetna Commercial |
$1,267.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,283.88
|
| Rate for Payer: Cash Price |
$823.00
|
| Rate for Payer: Cigna Commercial |
$1,366.18
|
| Rate for Payer: First Health Commercial |
$1,563.70
|
| Rate for Payer: Humana Commercial |
$1,399.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,349.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,214.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$493.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,448.48
|
| Rate for Payer: Ohio Health Group HMO |
$1,234.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,316.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,432.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,135.74
|
| Rate for Payer: PHCS Commercial |
$1,580.16
|
| Rate for Payer: United Healthcare All Payer |
$1,448.48
|
|
|
RESP VIRUS MOLECULAR PANEL
|
Facility
|
IP
|
$975.00
|
|
|
Service Code
|
HCPCS 87633
|
| Hospital Charge Code |
30001389
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$292.50 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$782.92
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$809.25
|
| Rate for Payer: First Health Commercial |
$926.25
|
| Rate for Payer: Humana Commercial |
$828.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$799.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$719.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$292.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$858.00
|
| Rate for Payer: Ohio Health Group HMO |
$731.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.75
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
RESP VIRUS MOLECULAR PANEL
|
Professional
|
Both
|
$975.00
|
|
|
Service Code
|
HCPCS 87633
|
| Hospital Charge Code |
30001389
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$250.07 |
| Max. Negotiated Rate |
$649.75 |
| Rate for Payer: Ambetter Exchange |
$416.78
|
| Rate for Payer: Buckeye Individual/Medicaid |
$416.78
|
| Rate for Payer: Buckeye Medicare Advantage |
$416.78
|
| Rate for Payer: CareSource Just4Me Medicare |
$500.14
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$649.75
|
| Rate for Payer: Healthspan PPO |
$429.68
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$416.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$416.78
|
| Rate for Payer: Multiplan PHCS |
$585.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$541.81
|
| Rate for Payer: UHCCP Medicaid |
$341.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$250.07
|
| Rate for Payer: Wellcare Medicare Advantage |
$416.78
|
|
|
RESP VIRUS MOLECULAR PANEL
|
Facility
|
OP
|
$975.00
|
|
|
Service Code
|
HCPCS 87633
|
| Hospital Charge Code |
30001389
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$416.78 |
| Max. Negotiated Rate |
$936.00 |
| Rate for Payer: Aetna Commercial |
$750.75
|
| Rate for Payer: Anthem Medicaid |
$416.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$416.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$782.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$583.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$416.78
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cash Price |
$487.50
|
| Rate for Payer: Cigna Commercial |
$809.25
|
| Rate for Payer: First Health Commercial |
$926.25
|
| Rate for Payer: Humana Commercial |
$828.75
|
| Rate for Payer: Humana KY Medicaid |
$416.78
|
| Rate for Payer: Humana Medicare Advantage |
$416.78
|
| Rate for Payer: Kentucky WC Medicaid |
$420.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$799.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$719.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$500.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$858.00
|
| Rate for Payer: Ohio Health Group HMO |
$731.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$780.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$848.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$672.75
|
| Rate for Payer: PHCS Commercial |
$936.00
|
| Rate for Payer: United Healthcare All Payer |
$858.00
|
|
|
RESTASIS 0.05% VIAL
|
Facility
|
IP
|
$27.76
|
|
|
Service Code
|
NDC 23916330
|
| Hospital Charge Code |
25001319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Commercial |
$21.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.65
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cigna Commercial |
$23.04
|
| Rate for Payer: First Health Commercial |
$26.37
|
| Rate for Payer: Humana Commercial |
$23.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.43
|
| Rate for Payer: Ohio Health Group HMO |
$20.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.15
|
| Rate for Payer: PHCS Commercial |
$26.65
|
| Rate for Payer: United Healthcare All Payer |
$24.43
|
|
|
RESTASIS 0.05% VIAL
|
Facility
|
OP
|
$27.76
|
|
|
Service Code
|
NDC 23916330
|
| Hospital Charge Code |
25001319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.33 |
| Max. Negotiated Rate |
$26.65 |
| Rate for Payer: Aetna Commercial |
$21.38
|
| Rate for Payer: Anthem Medicaid |
$9.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$21.65
|
| Rate for Payer: Cash Price |
$13.88
|
| Rate for Payer: Cigna Commercial |
$23.04
|
| Rate for Payer: First Health Commercial |
$26.37
|
| Rate for Payer: Humana Commercial |
$23.60
|
| Rate for Payer: Humana KY Medicaid |
$9.55
|
| Rate for Payer: Kentucky WC Medicaid |
$9.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$24.43
|
| Rate for Payer: Ohio Health Group HMO |
$20.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.15
|
| Rate for Payer: PHCS Commercial |
$26.65
|
| Rate for Payer: United Healthcare All Payer |
$24.43
|
|
|
REST MOD CALCAR BODY 21 +20MM
|
Facility
|
IP
|
$20,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,104.40 |
| Max. Negotiated Rate |
$19,534.08 |
| Rate for Payer: Aetna Commercial |
$15,667.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,871.44
|
| Rate for Payer: Cash Price |
$10,174.00
|
| Rate for Payer: Cigna Commercial |
$16,888.84
|
| Rate for Payer: First Health Commercial |
$19,330.60
|
| Rate for Payer: Humana Commercial |
$17,295.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,685.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,016.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,104.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,906.24
|
| Rate for Payer: Ohio Health Group HMO |
$15,261.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,278.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,702.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,040.12
|
| Rate for Payer: PHCS Commercial |
$19,534.08
|
| Rate for Payer: United Healthcare All Payer |
$17,906.24
|
|
|
REST MOD CALCAR BODY 21 +20MM
|
Facility
|
OP
|
$20,348.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,104.40 |
| Max. Negotiated Rate |
$19,534.08 |
| Rate for Payer: Aetna Commercial |
$15,667.96
|
| Rate for Payer: Anthem Medicaid |
$6,997.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,871.44
|
| Rate for Payer: Cash Price |
$10,174.00
|
| Rate for Payer: Cigna Commercial |
$16,888.84
|
| Rate for Payer: First Health Commercial |
$19,330.60
|
| Rate for Payer: Humana Commercial |
$17,295.80
|
| Rate for Payer: Humana KY Medicaid |
$6,997.68
|
| Rate for Payer: Kentucky WC Medicaid |
$7,068.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,685.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,016.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,104.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,138.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,906.24
|
| Rate for Payer: Ohio Health Group HMO |
$15,261.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,278.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,702.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,040.12
|
| Rate for Payer: PHCS Commercial |
$19,534.08
|
| Rate for Payer: United Healthcare All Payer |
$17,906.24
|
|
|
RESTOCKING FEE HEARING AID
|
Facility
|
OP
|
$120.00
|
|
| Hospital Charge Code |
27000131
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem Medicaid |
$41.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Humana KY Medicaid |
$41.27
|
| Rate for Payer: Kentucky WC Medicaid |
$41.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$42.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RESTOCKING FEE HEARING AID
|
Facility
|
IP
|
$120.00
|
|
| Hospital Charge Code |
27000131
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$115.20 |
| Rate for Payer: Aetna Commercial |
$92.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$93.60
|
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Cigna Commercial |
$99.60
|
| Rate for Payer: First Health Commercial |
$114.00
|
| Rate for Payer: Humana Commercial |
$102.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$98.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$88.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$105.60
|
| Rate for Payer: Ohio Health Group HMO |
$90.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$96.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$104.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$82.80
|
| Rate for Payer: PHCS Commercial |
$115.20
|
| Rate for Payer: United Healthcare All Payer |
$105.60
|
|
|
RESTOCKING FEE HEARING AID SP
|
Professional
|
Both
|
$120.00
|
|
| Hospital Charge Code |
47000105
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$42.00 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Cash Price |
$60.00
|
| Rate for Payer: Multiplan PHCS |
$72.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$84.00
|
| Rate for Payer: UHCCP Medicaid |
$42.00
|
|
|
RESTORATION DIST STEM 14*195MM
|
Facility
|
IP
|
$21,416.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,425.02 |
| Max. Negotiated Rate |
$20,560.08 |
| Rate for Payer: Aetna Commercial |
$16,490.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,705.06
|
| Rate for Payer: Cash Price |
$10,708.38
|
| Rate for Payer: Cigna Commercial |
$17,775.90
|
| Rate for Payer: First Health Commercial |
$20,345.91
|
| Rate for Payer: Humana Commercial |
$18,204.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,561.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,805.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,425.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,846.74
|
| Rate for Payer: Ohio Health Group HMO |
$16,062.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,133.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,632.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,777.56
|
| Rate for Payer: PHCS Commercial |
$20,560.08
|
| Rate for Payer: United Healthcare All Payer |
$18,846.74
|
|
|
RESTORATION DIST STEM 14*195MM
|
Facility
|
OP
|
$21,416.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,425.02 |
| Max. Negotiated Rate |
$20,560.08 |
| Rate for Payer: Aetna Commercial |
$16,490.90
|
| Rate for Payer: Anthem Medicaid |
$7,365.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,705.06
|
| Rate for Payer: Cash Price |
$10,708.38
|
| Rate for Payer: Cigna Commercial |
$17,775.90
|
| Rate for Payer: First Health Commercial |
$20,345.91
|
| Rate for Payer: Humana Commercial |
$18,204.24
|
| Rate for Payer: Humana KY Medicaid |
$7,365.22
|
| Rate for Payer: Kentucky WC Medicaid |
$7,440.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,561.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,805.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,425.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,513.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,846.74
|
| Rate for Payer: Ohio Health Group HMO |
$16,062.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17,133.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18,632.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$14,777.56
|
| Rate for Payer: PHCS Commercial |
$20,560.08
|
| Rate for Payer: United Healthcare All Payer |
$18,846.74
|
|
|
RESTORATION DIST STEM 15*155MM
|
Facility
|
IP
|
$18,891.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,667.31 |
| Max. Negotiated Rate |
$18,135.41 |
| Rate for Payer: Aetna Commercial |
$14,546.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,735.02
|
| Rate for Payer: Cash Price |
$9,445.52
|
| Rate for Payer: Cigna Commercial |
$15,679.57
|
| Rate for Payer: First Health Commercial |
$17,946.50
|
| Rate for Payer: Humana Commercial |
$16,057.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,490.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,941.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,667.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,624.12
|
| Rate for Payer: Ohio Health Group HMO |
$14,168.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,112.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,435.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,034.82
|
| Rate for Payer: PHCS Commercial |
$18,135.41
|
| Rate for Payer: United Healthcare All Payer |
$16,624.12
|
|
|
RESTORATION DIST STEM 15*155MM
|
Facility
|
OP
|
$18,891.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,667.31 |
| Max. Negotiated Rate |
$18,135.41 |
| Rate for Payer: Aetna Commercial |
$14,546.11
|
| Rate for Payer: Anthem Medicaid |
$6,496.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,735.02
|
| Rate for Payer: Cash Price |
$9,445.52
|
| Rate for Payer: Cigna Commercial |
$15,679.57
|
| Rate for Payer: First Health Commercial |
$17,946.50
|
| Rate for Payer: Humana Commercial |
$16,057.39
|
| Rate for Payer: Humana KY Medicaid |
$6,496.63
|
| Rate for Payer: Kentucky WC Medicaid |
$6,562.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,490.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,941.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,667.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,626.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,624.12
|
| Rate for Payer: Ohio Health Group HMO |
$14,168.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,112.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,435.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,034.82
|
| Rate for Payer: PHCS Commercial |
$18,135.41
|
| Rate for Payer: United Healthcare All Payer |
$16,624.12
|
|
|
RESTORATION DIST STEM 18*155MM
|
Facility
|
IP
|
$18,891.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,667.31 |
| Max. Negotiated Rate |
$18,135.41 |
| Rate for Payer: Aetna Commercial |
$14,546.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,735.02
|
| Rate for Payer: Cash Price |
$9,445.52
|
| Rate for Payer: Cigna Commercial |
$15,679.57
|
| Rate for Payer: First Health Commercial |
$17,946.50
|
| Rate for Payer: Humana Commercial |
$16,057.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,490.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,941.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,667.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,624.12
|
| Rate for Payer: Ohio Health Group HMO |
$14,168.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,112.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,435.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,034.82
|
| Rate for Payer: PHCS Commercial |
$18,135.41
|
| Rate for Payer: United Healthcare All Payer |
$16,624.12
|
|
|
RESTORATION DIST STEM 18*155MM
|
Facility
|
OP
|
$18,891.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,667.31 |
| Max. Negotiated Rate |
$18,135.41 |
| Rate for Payer: Aetna Commercial |
$14,546.11
|
| Rate for Payer: Anthem Medicaid |
$6,496.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,735.02
|
| Rate for Payer: Cash Price |
$9,445.52
|
| Rate for Payer: Cigna Commercial |
$15,679.57
|
| Rate for Payer: First Health Commercial |
$17,946.50
|
| Rate for Payer: Humana Commercial |
$16,057.39
|
| Rate for Payer: Humana KY Medicaid |
$6,496.63
|
| Rate for Payer: Kentucky WC Medicaid |
$6,562.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,490.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,941.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,667.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,626.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,624.12
|
| Rate for Payer: Ohio Health Group HMO |
$14,168.29
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,112.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,435.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,034.82
|
| Rate for Payer: PHCS Commercial |
$18,135.41
|
| Rate for Payer: United Healthcare All Payer |
$16,624.12
|
|
|
RESTORATION GAP RING 48MM
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATION GAP RING 48MM
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATION GAP RING 52MM
|
Facility
|
IP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
|
RESTORATION GAP RING 52MM
|
Facility
|
OP
|
$13,911.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,173.32 |
| Max. Negotiated Rate |
$13,354.62 |
| Rate for Payer: Aetna Commercial |
$10,711.52
|
| Rate for Payer: Anthem Medicaid |
$4,784.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,850.63
|
| Rate for Payer: Cash Price |
$6,955.53
|
| Rate for Payer: Cigna Commercial |
$11,546.18
|
| Rate for Payer: First Health Commercial |
$13,215.51
|
| Rate for Payer: Humana Commercial |
$11,824.40
|
| Rate for Payer: Humana KY Medicaid |
$4,784.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,832.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,407.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,266.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,173.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,880.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,241.73
|
| Rate for Payer: Ohio Health Group HMO |
$10,433.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,128.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,102.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,598.63
|
| Rate for Payer: PHCS Commercial |
$13,354.62
|
| Rate for Payer: United Healthcare All Payer |
$12,241.73
|
|
