|
BREAST IMPLANT FULL SCF-770
|
Facility
|
OP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem Medicaid |
$2,657.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Humana KY Medicaid |
$2,657.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,684.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,710.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
|
BREAST IMPLANT FULL SCF-770
|
Facility
|
IP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
|
BREAST IMPLANT SALINE 425CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BREAST IMPLANT SALINE 425CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BREAST IMP MEMORYGEL HIGH 450C
|
Facility
|
OP
|
$5,630.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.90 |
| Max. Negotiated Rate |
$5,404.80 |
| Rate for Payer: Aetna Commercial |
$4,335.10
|
| Rate for Payer: Anthem Medicaid |
$1,936.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,391.40
|
| Rate for Payer: Cash Price |
$2,815.00
|
| Rate for Payer: Cigna Commercial |
$4,672.90
|
| Rate for Payer: First Health Commercial |
$5,348.50
|
| Rate for Payer: Humana Commercial |
$4,785.50
|
| Rate for Payer: Humana KY Medicaid |
$1,936.16
|
| Rate for Payer: Kentucky WC Medicaid |
$1,955.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,616.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,154.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,689.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,975.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,954.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,126.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$731.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,745.30
|
| Rate for Payer: PHCS Commercial |
$5,404.80
|
| Rate for Payer: United Healthcare All Payer |
$4,954.40
|
|
|
BREAST IMP MEMORYGEL HIGH 450C
|
Facility
|
IP
|
$5,630.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$731.90 |
| Max. Negotiated Rate |
$5,404.80 |
| Rate for Payer: Aetna Commercial |
$4,335.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,391.40
|
| Rate for Payer: Cash Price |
$2,815.00
|
| Rate for Payer: Cigna Commercial |
$4,672.90
|
| Rate for Payer: First Health Commercial |
$5,348.50
|
| Rate for Payer: Humana Commercial |
$4,785.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,616.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,154.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,689.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,954.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,222.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,126.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$731.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,745.30
|
| Rate for Payer: PHCS Commercial |
$5,404.80
|
| Rate for Payer: United Healthcare All Payer |
$4,954.40
|
|
|
BREAST IMP MEMORYGEL MOD+ 450
|
Facility
|
OP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem Medicaid |
$1,906.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Humana KY Medicaid |
$1,906.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,925.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,944.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BREAST IMP MEMORYGEL MOD+ 450
|
Facility
|
IP
|
$5,542.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$720.52 |
| Max. Negotiated Rate |
$5,320.80 |
| Rate for Payer: Aetna Commercial |
$4,267.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,323.15
|
| Rate for Payer: Cash Price |
$2,771.25
|
| Rate for Payer: Cigna Commercial |
$4,600.28
|
| Rate for Payer: First Health Commercial |
$5,265.38
|
| Rate for Payer: Humana Commercial |
$4,711.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,544.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,090.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,662.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,877.40
|
| Rate for Payer: Ohio Health Group HMO |
$4,156.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,108.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$720.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,718.18
|
| Rate for Payer: PHCS Commercial |
$5,320.80
|
| Rate for Payer: United Healthcare All Payer |
$4,877.40
|
|
|
BREAST IMP MOD PROFILE 120CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 120CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 150CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 150CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 158CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 158CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 176CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 176CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 180CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 180CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 194CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 194CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 210CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD PROFILE 210CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 213CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 213CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP MOD+ PROFILE 234CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
