|
RESTYLANE LYFT
|
Facility
|
IP
|
$675.00
|
|
| Hospital Charge Code |
22200029
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$202.50 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$519.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$526.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$560.25
|
| Rate for Payer: First Health Commercial |
$641.25
|
| Rate for Payer: Humana Commercial |
$573.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$553.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.00
|
| Rate for Payer: Ohio Health Group HMO |
$506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$587.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.75
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
|
RESTYLANE LYFT
|
Professional
|
Both
|
$675.00
|
|
| Hospital Charge Code |
22200029
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$236.25 |
| Max. Negotiated Rate |
$472.50 |
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Multiplan PHCS |
$405.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$472.50
|
| Rate for Payer: UHCCP Medicaid |
$236.25
|
|
|
RESTYLANE LYFT
|
Facility
|
OP
|
$675.00
|
|
| Hospital Charge Code |
22200029
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$202.50 |
| Max. Negotiated Rate |
$648.00 |
| Rate for Payer: Aetna Commercial |
$519.75
|
| Rate for Payer: Anthem Medicaid |
$232.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$526.50
|
| Rate for Payer: Cash Price |
$337.50
|
| Rate for Payer: Cigna Commercial |
$560.25
|
| Rate for Payer: First Health Commercial |
$641.25
|
| Rate for Payer: Humana Commercial |
$573.75
|
| Rate for Payer: Humana KY Medicaid |
$232.13
|
| Rate for Payer: Kentucky WC Medicaid |
$234.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$553.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$498.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$202.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$236.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$594.00
|
| Rate for Payer: Ohio Health Group HMO |
$506.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$587.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$465.75
|
| Rate for Payer: PHCS Commercial |
$648.00
|
| Rate for Payer: United Healthcare All Payer |
$594.00
|
|
|
RESTYLANE SILK
|
Facility
|
OP
|
$600.00
|
|
| Hospital Charge Code |
22200027
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem Medicaid |
$206.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Humana KY Medicaid |
$206.34
|
| Rate for Payer: Kentucky WC Medicaid |
$208.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
RESTYLANE SILK
|
Professional
|
Both
|
$600.00
|
|
| Hospital Charge Code |
22200027
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$210.00 |
| Max. Negotiated Rate |
$420.00 |
| 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
|
|
|
RESTYLANE SILK
|
Facility
|
IP
|
$600.00
|
|
| Hospital Charge Code |
22200027
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$180.00 |
| Max. Negotiated Rate |
$576.00 |
| Rate for Payer: Aetna Commercial |
$462.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$468.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna Commercial |
$498.00
|
| Rate for Payer: First Health Commercial |
$570.00
|
| Rate for Payer: Humana Commercial |
$510.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$492.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$528.00
|
| Rate for Payer: Ohio Health Group HMO |
$450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$480.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$522.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$414.00
|
| Rate for Payer: PHCS Commercial |
$576.00
|
| Rate for Payer: United Healthcare All Payer |
$528.00
|
|
|
RESURF PAT W/JRNY PEG 26MM
|
Facility
|
OP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem Medicaid |
$2,341.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Humana KY Medicaid |
$2,341.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 26MM
|
Facility
|
IP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 29MM
|
Facility
|
OP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem Medicaid |
$2,341.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Humana KY Medicaid |
$2,341.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 29MM
|
Facility
|
IP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 32MM
|
Facility
|
IP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 32MM
|
Facility
|
OP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem Medicaid |
$2,341.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Humana KY Medicaid |
$2,341.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 35MM
|
Facility
|
OP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem Medicaid |
$2,341.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Humana KY Medicaid |
$2,341.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 35MM
|
Facility
|
IP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 38MM
|
Facility
|
IP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 38MM
|
Facility
|
OP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem Medicaid |
$2,341.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Humana KY Medicaid |
$2,341.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 41MM
|
Facility
|
OP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem Medicaid |
$2,341.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Humana KY Medicaid |
$2,341.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,365.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,388.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF PAT W/JRNY PEG 41MM
|
Facility
|
IP
|
$6,807.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,042.36 |
| Max. Negotiated Rate |
$6,535.55 |
| Rate for Payer: Aetna Commercial |
$5,242.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,310.13
|
| Rate for Payer: Cash Price |
$3,403.93
|
| Rate for Payer: Cigna Commercial |
$5,650.52
|
| Rate for Payer: First Health Commercial |
$6,467.47
|
| Rate for Payer: Humana Commercial |
$5,786.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,582.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,024.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,042.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,990.92
|
| Rate for Payer: Ohio Health Group HMO |
$5,105.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,446.29
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,922.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,697.42
|
| Rate for Payer: PHCS Commercial |
$6,535.55
|
| Rate for Payer: United Healthcare All Payer |
$5,990.92
|
|
|
RESURF W/JRNY ELIP PAT PEG 29
|
Facility
|
IP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 29
|
Facility
|
OP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem Medicaid |
$1,139.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Humana KY Medicaid |
$1,139.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,150.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,162.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 32
|
Facility
|
OP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem Medicaid |
$1,139.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Humana KY Medicaid |
$1,139.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,150.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,162.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 32
|
Facility
|
IP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 35
|
Facility
|
OP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem Medicaid |
$1,139.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Humana KY Medicaid |
$1,139.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,150.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,162.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 35
|
Facility
|
IP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
|
RESURF W/JRNY ELIP PAT PEG 38
|
Facility
|
IP
|
$3,312.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$993.75 |
| Max. Negotiated Rate |
$3,180.00 |
| Rate for Payer: Aetna Commercial |
$2,550.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,583.75
|
| Rate for Payer: Cash Price |
$1,656.25
|
| Rate for Payer: Cigna Commercial |
$2,749.38
|
| Rate for Payer: First Health Commercial |
$3,146.88
|
| Rate for Payer: Humana Commercial |
$2,815.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,716.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,444.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$993.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,915.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,484.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,650.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,881.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,285.62
|
| Rate for Payer: PHCS Commercial |
$3,180.00
|
| Rate for Payer: United Healthcare All Payer |
$2,915.00
|
|
