|
BREAST EXPANDER MED HGHT 450CC
|
Facility
|
OP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem Medicaid |
$2,757.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Humana KY Medicaid |
$2,757.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,812.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER MED HGHT 450CC
|
Facility
|
IP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER MED HGHT 550CC
|
Facility
|
OP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem Medicaid |
$2,820.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Humana KY Medicaid |
$2,820.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
BREAST EXPANDER MED HGHT 550CC
|
Facility
|
IP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
BREAST EXPANDER MED HGHT 650CC
|
Facility
|
OP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem Medicaid |
$2,757.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Humana KY Medicaid |
$2,757.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,812.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER MED HGHT 650CC
|
Facility
|
IP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDER MOD HGHT 500CC
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST EXPANDER MOD HGHT 500CC
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST EXPANDER MOD HGHT 600CC
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST EXPANDER MOD HGHT 600CC
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST EXPANDER MOD HGHT 700CC
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST EXPANDER MOD HGHT 700CC
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST EXPANDER TABBED 300CC
|
Facility
|
IP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
BREAST EXPANDER TABBED 300CC
|
Facility
|
OP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem Medicaid |
$2,349.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana KY Medicaid |
$2,349.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,373.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
BREAST EXPANDER TABBED 400CC
|
Facility
|
OP
|
$8,821.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.53 |
| Max. Negotiated Rate |
$8,468.88 |
| Rate for Payer: Aetna Commercial |
$6,792.75
|
| Rate for Payer: Anthem Medicaid |
$3,033.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,880.97
|
| Rate for Payer: Cash Price |
$4,410.88
|
| Rate for Payer: Cigna Commercial |
$7,322.05
|
| Rate for Payer: First Health Commercial |
$8,380.66
|
| Rate for Payer: Humana Commercial |
$7,498.49
|
| Rate for Payer: Humana KY Medicaid |
$3,033.80
|
| Rate for Payer: Kentucky WC Medicaid |
$3,064.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,233.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,510.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,646.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,094.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,763.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,616.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,057.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,674.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,087.01
|
| Rate for Payer: PHCS Commercial |
$8,468.88
|
| Rate for Payer: United Healthcare All Payer |
$7,763.14
|
|
|
BREAST EXPANDER TABBED 400CC
|
Facility
|
IP
|
$8,821.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,646.53 |
| Max. Negotiated Rate |
$8,468.88 |
| Rate for Payer: Aetna Commercial |
$6,792.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,880.97
|
| Rate for Payer: Cash Price |
$4,410.88
|
| Rate for Payer: Cigna Commercial |
$7,322.05
|
| Rate for Payer: First Health Commercial |
$8,380.66
|
| Rate for Payer: Humana Commercial |
$7,498.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,233.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,510.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,646.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,763.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,616.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,057.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,674.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,087.01
|
| Rate for Payer: PHCS Commercial |
$8,468.88
|
| Rate for Payer: United Healthcare All Payer |
$7,763.14
|
|
|
BREAST EXPANDER TABBED 600CC
|
Facility
|
OP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem Medicaid |
$2,349.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Humana KY Medicaid |
$2,349.70
|
| Rate for Payer: Kentucky WC Medicaid |
$2,373.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,396.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
BREAST EXPANDER TABBED 600CC
|
Facility
|
IP
|
$6,832.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,049.75 |
| Max. Negotiated Rate |
$6,559.20 |
| Rate for Payer: Aetna Commercial |
$5,261.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,329.35
|
| Rate for Payer: Cash Price |
$3,416.25
|
| Rate for Payer: Cigna Commercial |
$5,670.98
|
| Rate for Payer: First Health Commercial |
$6,490.88
|
| Rate for Payer: Humana Commercial |
$5,807.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,602.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,042.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,049.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,012.60
|
| Rate for Payer: Ohio Health Group HMO |
$5,124.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,466.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,944.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,714.43
|
| Rate for Payer: PHCS Commercial |
$6,559.20
|
| Rate for Payer: United Healthcare All Payer |
$6,012.60
|
|
|
BREAST EXPANDR SHRT HGHT 375CC
|
Facility
|
OP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem Medicaid |
$2,757.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Humana KY Medicaid |
$2,757.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,785.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,812.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST EXPANDR SHRT HGHT 375CC
|
Facility
|
IP
|
$8,018.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,405.62 |
| Max. Negotiated Rate |
$7,698.00 |
| Rate for Payer: Aetna Commercial |
$6,174.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,254.62
|
| Rate for Payer: Cash Price |
$4,009.38
|
| Rate for Payer: Cigna Commercial |
$6,655.56
|
| Rate for Payer: First Health Commercial |
$7,617.81
|
| Rate for Payer: Humana Commercial |
$6,815.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,575.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,917.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,405.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,056.50
|
| Rate for Payer: Ohio Health Group HMO |
$6,014.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,415.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,976.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,532.94
|
| Rate for Payer: PHCS Commercial |
$7,698.00
|
| Rate for Payer: United Healthcare All Payer |
$7,056.50
|
|
|
BREAST HSC GEL HIGH 190CC
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST HSC GEL HIGH 190CC
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST HSC GEL HIGH 205CC
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST HSC GEL HIGH 205CC
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST HSC GEL SMTH MOD+ 175CC
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
