|
SLEEP LATENCY
|
Facility
|
OP
|
$3,260.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
74000002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$423.80 |
| Max. Negotiated Rate |
$3,129.60 |
| Rate for Payer: Aetna Commercial |
$2,510.20
|
| Rate for Payer: Anthem Medicaid |
$1,121.11
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,542.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cash Price |
$1,630.00
|
| Rate for Payer: Cigna Commercial |
$2,705.80
|
| Rate for Payer: First Health Commercial |
$3,097.00
|
| Rate for Payer: Humana Commercial |
$2,771.00
|
| Rate for Payer: Humana KY Medicaid |
$1,121.11
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,132.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,673.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,405.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,143.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,868.80
|
| Rate for Payer: Ohio Health Group HMO |
$2,445.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$652.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$423.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,010.60
|
| Rate for Payer: PHCS Commercial |
$3,129.60
|
| Rate for Payer: United Healthcare All Payer |
$2,868.80
|
|
|
SLEEP LATENCY(P
|
Professional
|
Both
|
$185.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
740P0002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$64.75 |
| Max. Negotiated Rate |
$959.14 |
| Rate for Payer: Aetna Commercial |
$641.16
|
| Rate for Payer: Anthem Medicaid |
$213.89
|
| Rate for Payer: Buckeye Medicare Advantage |
$185.00
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cash Price |
$92.50
|
| Rate for Payer: Cigna Commercial |
$959.14
|
| Rate for Payer: Healthspan PPO |
$560.73
|
| Rate for Payer: Humana Medicaid |
$213.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$73.98
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$218.17
|
| Rate for Payer: Molina Healthcare Passport |
$213.89
|
| Rate for Payer: Multiplan PHCS |
$111.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$129.50
|
| Rate for Payer: UHCCP Medicaid |
$64.75
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$216.03
|
|
|
SLEEP LATENCY(T
|
Facility
|
OP
|
$3,075.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
740T0002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem Medicaid |
$1,057.49
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Humana KY Medicaid |
$1,057.49
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1,068.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,078.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
SLEEP LATENCY(T
|
Facility
|
IP
|
$3,075.00
|
|
|
Service Code
|
HCPCS 95805
|
| Hospital Charge Code |
740T0002
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$399.75 |
| Max. Negotiated Rate |
$2,952.00 |
| Rate for Payer: Aetna Commercial |
$2,367.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,398.50
|
| Rate for Payer: Cash Price |
$1,537.50
|
| Rate for Payer: Cigna Commercial |
$2,552.25
|
| Rate for Payer: First Health Commercial |
$2,921.25
|
| Rate for Payer: Humana Commercial |
$2,613.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,521.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,269.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$922.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,706.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,306.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$615.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$399.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$953.25
|
| Rate for Payer: PHCS Commercial |
$2,952.00
|
| Rate for Payer: United Healthcare All Payer |
$2,706.00
|
|
|
SLEEP STUDY ATTENDED
|
Facility
|
IP
|
$2,390.00
|
|
|
Service Code
|
HCPCS 95807
|
| Hospital Charge Code |
51000035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$310.70 |
| Max. Negotiated Rate |
$2,294.40 |
| Rate for Payer: Aetna Commercial |
$1,840.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,864.20
|
| Rate for Payer: Cash Price |
$1,195.00
|
| Rate for Payer: Cigna Commercial |
$1,983.70
|
| Rate for Payer: First Health Commercial |
$2,270.50
|
| Rate for Payer: Humana Commercial |
$2,031.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,959.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,763.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,103.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,792.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$478.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$310.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$740.90
|
| Rate for Payer: PHCS Commercial |
$2,294.40
|
| Rate for Payer: United Healthcare All Payer |
$2,103.20
|
|
|
SLEEP STUDY ATTENDED
|
Professional
|
Both
|
$2,390.00
|
|
|
Service Code
|
HCPCS 95807
|
| Hospital Charge Code |
51000035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.78 |
| Max. Negotiated Rate |
$2,390.00 |
| Rate for Payer: Aetna Commercial |
$747.97
|
| Rate for Payer: Anthem Medicaid |
$299.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,390.00
|
| Rate for Payer: Cash Price |
$1,195.00
|
| Rate for Payer: Cash Price |
$1,195.00
|
| Rate for Payer: Cigna Commercial |
$788.13
|
| Rate for Payer: Healthspan PPO |
$654.14
|
| Rate for Payer: Humana Medicaid |
$299.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$305.67
|
| Rate for Payer: Molina Healthcare Passport |
$299.68
|
| Rate for Payer: Multiplan PHCS |
$1,434.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,673.00
|
| Rate for Payer: UHCCP Medicaid |
$836.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$302.68
|
|
|
SLEEP STUDY ATTENDED
|
Facility
|
OP
|
$2,390.00
|
|
|
Service Code
|
HCPCS 95807
|
| Hospital Charge Code |
51000035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$310.70 |
| Max. Negotiated Rate |
$2,294.40 |
| Rate for Payer: Aetna Commercial |
$1,840.30
|
| Rate for Payer: Anthem Medicaid |
$821.92
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,864.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$1,195.00
|
| Rate for Payer: Cash Price |
$1,195.00
|
| Rate for Payer: Cigna Commercial |
$1,983.70
|
| Rate for Payer: First Health Commercial |
$2,270.50
|
| Rate for Payer: Humana Commercial |
$2,031.50
|
| Rate for Payer: Humana KY Medicaid |
$821.92
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$830.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,959.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,763.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$838.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,103.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,792.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$478.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$310.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$740.90
|
| Rate for Payer: PHCS Commercial |
$2,294.40
|
| Rate for Payer: United Healthcare All Payer |
$2,103.20
|
|
|
SLEEP STUDY ATTENDED(P
|
Professional
|
Both
|
$400.00
|
|
|
Service Code
|
HCPCS 95807
|
| Hospital Charge Code |
510P0035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$75.78 |
| Max. Negotiated Rate |
$788.13 |
| Rate for Payer: Aetna Commercial |
$747.97
|
| Rate for Payer: Anthem Medicaid |
$299.68
|
| Rate for Payer: Buckeye Medicare Advantage |
$400.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cash Price |
$200.00
|
| Rate for Payer: Cigna Commercial |
$788.13
|
| Rate for Payer: Healthspan PPO |
$654.14
|
| Rate for Payer: Humana Medicaid |
$299.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$75.78
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$305.67
|
| Rate for Payer: Molina Healthcare Passport |
$299.68
|
| Rate for Payer: Multiplan PHCS |
$240.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$280.00
|
| Rate for Payer: UHCCP Medicaid |
$140.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$302.68
|
|
|
SLEEP STUDY ATTENDED(T
|
Facility
|
OP
|
$1,990.00
|
|
|
Service Code
|
HCPCS 95807
|
| Hospital Charge Code |
510T0035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$258.70 |
| Max. Negotiated Rate |
$1,910.40 |
| Rate for Payer: Aetna Commercial |
$1,532.30
|
| Rate for Payer: Anthem Medicaid |
$684.36
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$463.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,552.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$648.89
|
| Rate for Payer: CareSource Just4Me Medicare |
$625.71
|
| Rate for Payer: Cash Price |
$995.00
|
| Rate for Payer: Cash Price |
$995.00
|
| Rate for Payer: Cigna Commercial |
$1,651.70
|
| Rate for Payer: First Health Commercial |
$1,890.50
|
| Rate for Payer: Humana Commercial |
$1,691.50
|
| Rate for Payer: Humana KY Medicaid |
$684.36
|
| Rate for Payer: Humana Medicare Advantage |
$463.49
|
| Rate for Payer: Kentucky WC Medicaid |
$691.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,631.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,468.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$556.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$698.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,751.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,492.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$398.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$258.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$616.90
|
| Rate for Payer: PHCS Commercial |
$1,910.40
|
| Rate for Payer: United Healthcare All Payer |
$1,751.20
|
|
|
SLEEP STUDY ATTENDED(T
|
Facility
|
IP
|
$1,990.00
|
|
|
Service Code
|
HCPCS 95807
|
| Hospital Charge Code |
510T0035
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$258.70 |
| Max. Negotiated Rate |
$1,910.40 |
| Rate for Payer: Aetna Commercial |
$1,532.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,552.20
|
| Rate for Payer: Cash Price |
$995.00
|
| Rate for Payer: Cigna Commercial |
$1,651.70
|
| Rate for Payer: First Health Commercial |
$1,890.50
|
| Rate for Payer: Humana Commercial |
$1,691.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,631.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,468.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$597.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,751.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,492.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$398.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$258.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$616.90
|
| Rate for Payer: PHCS Commercial |
$1,910.40
|
| Rate for Payer: United Healthcare All Payer |
$1,751.20
|
|
|
SLEEVE LOBECTOMY
|
Facility
|
OP
|
$5,700.00
|
|
|
Service Code
|
HCPCS 32486
|
| Hospital Charge Code |
76101192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$741.00 |
| Max. Negotiated Rate |
$5,472.00 |
| Rate for Payer: Aetna Commercial |
$4,389.00
|
| Rate for Payer: Anthem Medicaid |
$1,960.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,446.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Cigna Commercial |
$4,731.00
|
| Rate for Payer: First Health Commercial |
$5,415.00
|
| Rate for Payer: Humana Commercial |
$4,845.00
|
| Rate for Payer: Humana KY Medicaid |
$1,960.23
|
| Rate for Payer: Kentucky WC Medicaid |
$1,980.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,674.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,206.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,710.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,999.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,016.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$741.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,767.00
|
| Rate for Payer: PHCS Commercial |
$5,472.00
|
| Rate for Payer: United Healthcare All Payer |
$5,016.00
|
|
|
SLEEVE LOBECTOMY
|
Professional
|
Both
|
$5,700.00
|
|
|
Service Code
|
HCPCS 32486
|
| Hospital Charge Code |
76101192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,189.69 |
| Max. Negotiated Rate |
$5,700.00 |
| Rate for Payer: Aetna Commercial |
$3,815.30
|
| Rate for Payer: Anthem Medicaid |
$1,189.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,700.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Cigna Commercial |
$3,509.82
|
| Rate for Payer: Healthspan PPO |
$2,978.88
|
| Rate for Payer: Humana Medicaid |
$1,189.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,279.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,213.48
|
| Rate for Payer: Molina Healthcare Passport |
$1,189.69
|
| Rate for Payer: Multiplan PHCS |
$3,420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,990.00
|
| Rate for Payer: UHCCP Medicaid |
$1,995.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,201.59
|
|
|
SLEEVE LOBECTOMY
|
Facility
|
IP
|
$5,700.00
|
|
|
Service Code
|
HCPCS 32486
|
| Hospital Charge Code |
76101192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$741.00 |
| Max. Negotiated Rate |
$5,472.00 |
| Rate for Payer: Aetna Commercial |
$4,389.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,446.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Cigna Commercial |
$4,731.00
|
| Rate for Payer: First Health Commercial |
$5,415.00
|
| Rate for Payer: Humana Commercial |
$4,845.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,674.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,206.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,710.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,016.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,275.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$741.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,767.00
|
| Rate for Payer: PHCS Commercial |
$5,472.00
|
| Rate for Payer: United Healthcare All Payer |
$5,016.00
|
|
|
SLEEVE LOBECTOMY(P
|
Professional
|
Both
|
$5,700.00
|
|
|
Service Code
|
HCPCS 32486
|
| Hospital Charge Code |
761P1192
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,189.69 |
| Max. Negotiated Rate |
$5,700.00 |
| Rate for Payer: Aetna Commercial |
$3,815.30
|
| Rate for Payer: Anthem Medicaid |
$1,189.69
|
| Rate for Payer: Buckeye Medicare Advantage |
$5,700.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Cash Price |
$2,850.00
|
| Rate for Payer: Cigna Commercial |
$3,509.82
|
| Rate for Payer: Healthspan PPO |
$2,978.88
|
| Rate for Payer: Humana Medicaid |
$1,189.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$3,279.91
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,213.48
|
| Rate for Payer: Molina Healthcare Passport |
$1,189.69
|
| Rate for Payer: Multiplan PHCS |
$3,420.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3,990.00
|
| Rate for Payer: UHCCP Medicaid |
$1,995.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,201.59
|
|
|
SLEEVE MODSTIKTITEW/HA LG26/27
|
Facility
|
IP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODSTIKTITEW/HA LG26/27
|
Facility
|
OP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem Medicaid |
$5,282.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Humana KY Medicaid |
$5,282.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,336.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,388.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODSTIKTITEW/HA MD26/27
|
Facility
|
OP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem Medicaid |
$5,282.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Humana KY Medicaid |
$5,282.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,336.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,388.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODSTIKTITEW/HA MD26/27
|
Facility
|
IP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODSTIKTITEW/HA SM12-13
|
Facility
|
IP
|
$15,144.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,968.72 |
| Max. Negotiated Rate |
$14,538.24 |
| Rate for Payer: Aetna Commercial |
$11,660.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,812.32
|
| Rate for Payer: Cash Price |
$7,572.00
|
| Rate for Payer: Cigna Commercial |
$12,569.52
|
| Rate for Payer: First Health Commercial |
$14,386.80
|
| Rate for Payer: Humana Commercial |
$12,872.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,418.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,176.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,543.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,326.72
|
| Rate for Payer: Ohio Health Group HMO |
$11,358.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,028.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,968.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,694.64
|
| Rate for Payer: PHCS Commercial |
$14,538.24
|
| Rate for Payer: United Healthcare All Payer |
$13,326.72
|
|
|
SLEEVE MODSTIKTITEW/HA SM12-13
|
Facility
|
OP
|
$15,144.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,968.72 |
| Max. Negotiated Rate |
$14,538.24 |
| Rate for Payer: Aetna Commercial |
$11,660.88
|
| Rate for Payer: Anthem Medicaid |
$5,208.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,812.32
|
| Rate for Payer: Cash Price |
$7,572.00
|
| Rate for Payer: Cigna Commercial |
$12,569.52
|
| Rate for Payer: First Health Commercial |
$14,386.80
|
| Rate for Payer: Humana Commercial |
$12,872.40
|
| Rate for Payer: Humana KY Medicaid |
$5,208.02
|
| Rate for Payer: Kentucky WC Medicaid |
$5,261.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,418.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,176.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,543.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,312.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,326.72
|
| Rate for Payer: Ohio Health Group HMO |
$11,358.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,028.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,968.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,694.64
|
| Rate for Payer: PHCS Commercial |
$14,538.24
|
| Rate for Payer: United Healthcare All Payer |
$13,326.72
|
|
|
SLEEVE MODSTIKTITEW/HA SM26/27
|
Facility
|
IP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODSTIKTITEW/HA SM26/27
|
Facility
|
OP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem Medicaid |
$5,282.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Humana KY Medicaid |
$5,282.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,336.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,388.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODULAR GRIT XS 26/27
|
Facility
|
IP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE MODULAR GRIT XS 26/27
|
Facility
|
OP
|
$15,360.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,996.80 |
| Max. Negotiated Rate |
$14,745.60 |
| Rate for Payer: Aetna Commercial |
$11,827.20
|
| Rate for Payer: Anthem Medicaid |
$5,282.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,980.80
|
| Rate for Payer: Cash Price |
$7,680.00
|
| Rate for Payer: Cigna Commercial |
$12,748.80
|
| Rate for Payer: First Health Commercial |
$14,592.00
|
| Rate for Payer: Humana Commercial |
$13,056.00
|
| Rate for Payer: Humana KY Medicaid |
$5,282.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,336.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,595.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,335.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,608.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,388.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,516.80
|
| Rate for Payer: Ohio Health Group HMO |
$11,520.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,996.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,761.60
|
| Rate for Payer: PHCS Commercial |
$14,745.60
|
| Rate for Payer: United Healthcare All Payer |
$13,516.80
|
|
|
SLEEVE TI MOD HEAD 12/14 TPR +
|
Facility
|
IP
|
$1,752.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$227.82 |
| Max. Negotiated Rate |
$1,682.40 |
| Rate for Payer: Aetna Commercial |
$1,349.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,366.95
|
| Rate for Payer: Cash Price |
$876.25
|
| Rate for Payer: Cigna Commercial |
$1,454.58
|
| Rate for Payer: First Health Commercial |
$1,664.88
|
| Rate for Payer: Humana Commercial |
$1,489.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,437.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,293.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,542.20
|
| Rate for Payer: Ohio Health Group HMO |
$1,314.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$350.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$227.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$543.28
|
| Rate for Payer: PHCS Commercial |
$1,682.40
|
| Rate for Payer: United Healthcare All Payer |
$1,542.20
|
|
