|
BREAST IMP INSPIRA X-FULL 700C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 750C
|
Facility
|
OP
|
$6,894.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,068.36 |
| Max. Negotiated Rate |
$6,618.77 |
| Rate for Payer: Aetna Commercial |
$5,308.80
|
| Rate for Payer: Anthem Medicaid |
$2,371.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,377.75
|
| Rate for Payer: Cash Price |
$3,447.28
|
| Rate for Payer: Cigna Commercial |
$5,722.48
|
| Rate for Payer: First Health Commercial |
$6,549.82
|
| Rate for Payer: Humana Commercial |
$5,860.37
|
| Rate for Payer: Humana KY Medicaid |
$2,371.04
|
| Rate for Payer: Kentucky WC Medicaid |
$2,395.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,653.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,088.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,068.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,418.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,067.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,170.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,515.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,998.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,757.24
|
| Rate for Payer: PHCS Commercial |
$6,618.77
|
| Rate for Payer: United Healthcare All Payer |
$6,067.20
|
|
|
BREAST IMP INSPIRA X-FULL 750C
|
Facility
|
IP
|
$6,894.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,068.36 |
| Max. Negotiated Rate |
$6,618.77 |
| Rate for Payer: Aetna Commercial |
$5,308.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,377.75
|
| Rate for Payer: Cash Price |
$3,447.28
|
| Rate for Payer: Cigna Commercial |
$5,722.48
|
| Rate for Payer: First Health Commercial |
$6,549.82
|
| Rate for Payer: Humana Commercial |
$5,860.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,653.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,088.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,068.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,067.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,170.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,515.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,998.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,757.24
|
| Rate for Payer: PHCS Commercial |
$6,618.77
|
| Rate for Payer: United Healthcare All Payer |
$6,067.20
|
|
|
BREAST IMP INSPIRA X-FULL 800C
|
Facility
|
OP
|
$6,894.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,068.36 |
| Max. Negotiated Rate |
$6,618.77 |
| Rate for Payer: Aetna Commercial |
$5,308.80
|
| Rate for Payer: Anthem Medicaid |
$2,371.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,377.75
|
| Rate for Payer: Cash Price |
$3,447.28
|
| Rate for Payer: Cigna Commercial |
$5,722.48
|
| Rate for Payer: First Health Commercial |
$6,549.82
|
| Rate for Payer: Humana Commercial |
$5,860.37
|
| Rate for Payer: Humana KY Medicaid |
$2,371.04
|
| Rate for Payer: Kentucky WC Medicaid |
$2,395.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,653.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,088.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,068.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,418.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,067.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,170.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,515.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,998.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,757.24
|
| Rate for Payer: PHCS Commercial |
$6,618.77
|
| Rate for Payer: United Healthcare All Payer |
$6,067.20
|
|
|
BREAST IMP INSPIRA X-FULL 800C
|
Facility
|
IP
|
$6,894.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,068.36 |
| Max. Negotiated Rate |
$6,618.77 |
| Rate for Payer: Aetna Commercial |
$5,308.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,377.75
|
| Rate for Payer: Cash Price |
$3,447.28
|
| Rate for Payer: Cigna Commercial |
$5,722.48
|
| Rate for Payer: First Health Commercial |
$6,549.82
|
| Rate for Payer: Humana Commercial |
$5,860.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,653.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,088.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,068.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,067.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,170.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,515.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,998.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,757.24
|
| Rate for Payer: PHCS Commercial |
$6,618.77
|
| Rate for Payer: United Healthcare All Payer |
$6,067.20
|
|
|
BREAST IMPLANT FULL SCF-770
|
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 IMPLANT FULL SCF-770
|
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 IMPLANT SALINE 330CC
|
Facility
|
IP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
BREAST IMPLANT SALINE 330CC
|
Facility
|
OP
|
$5,093.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,528.12 |
| Max. Negotiated Rate |
$4,890.00 |
| Rate for Payer: Aetna Commercial |
$3,922.19
|
| Rate for Payer: Anthem Medicaid |
$1,751.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,973.12
|
| Rate for Payer: Cash Price |
$2,546.88
|
| Rate for Payer: Cigna Commercial |
$4,227.81
|
| Rate for Payer: First Health Commercial |
$4,839.06
|
| Rate for Payer: Humana Commercial |
$4,329.69
|
| Rate for Payer: Humana KY Medicaid |
$1,751.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,769.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,176.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,759.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,528.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,786.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,482.50
|
| Rate for Payer: Ohio Health Group HMO |
$3,820.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,075.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,431.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,514.69
|
| Rate for Payer: PHCS Commercial |
$4,890.00
|
| Rate for Payer: United Healthcare All Payer |
$4,482.50
|
|
|
BREAST IMPLANT SALINE 425CC
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BREAST IMPLANT SALINE 425CC
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BREAST IMP MEMORYGEL HIGH 450C
|
Facility
|
IP
|
$5,675.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,702.50 |
| Max. Negotiated Rate |
$5,448.00 |
| Rate for Payer: Aetna Commercial |
$4,369.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,426.50
|
| Rate for Payer: Cash Price |
$2,837.50
|
| Rate for Payer: Cigna Commercial |
$4,710.25
|
| Rate for Payer: First Health Commercial |
$5,391.25
|
| Rate for Payer: Humana Commercial |
$4,823.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,653.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,188.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,702.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,994.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,256.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,937.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,915.75
|
| Rate for Payer: PHCS Commercial |
$5,448.00
|
| Rate for Payer: United Healthcare All Payer |
$4,994.00
|
|
|
BREAST IMP MEMORYGEL HIGH 450C
|
Facility
|
OP
|
$5,675.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,702.50 |
| Max. Negotiated Rate |
$5,448.00 |
| Rate for Payer: Aetna Commercial |
$4,369.75
|
| Rate for Payer: Anthem Medicaid |
$1,951.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,426.50
|
| Rate for Payer: Cash Price |
$2,837.50
|
| Rate for Payer: Cigna Commercial |
$4,710.25
|
| Rate for Payer: First Health Commercial |
$5,391.25
|
| Rate for Payer: Humana Commercial |
$4,823.75
|
| Rate for Payer: Humana KY Medicaid |
$1,951.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1,971.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,653.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,188.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,702.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,990.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,994.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,256.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,540.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,937.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,915.75
|
| Rate for Payer: PHCS Commercial |
$5,448.00
|
| Rate for Payer: United Healthcare All Payer |
$4,994.00
|
|
|
BREAST IMP MEMORYGEL MOD+ 450
|
Facility
|
OP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem Medicaid |
$1,919.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Humana KY Medicaid |
$1,919.39
|
| Rate for Payer: Kentucky WC Medicaid |
$1,938.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,957.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
|
BREAST IMP MEMORYGEL MOD+ 450
|
Facility
|
IP
|
$5,581.25
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,674.38 |
| Max. Negotiated Rate |
$5,358.00 |
| Rate for Payer: Aetna Commercial |
$4,297.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,353.38
|
| Rate for Payer: Cash Price |
$2,790.62
|
| Rate for Payer: Cigna Commercial |
$4,632.44
|
| Rate for Payer: First Health Commercial |
$5,302.19
|
| Rate for Payer: Humana Commercial |
$4,744.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,576.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,118.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,674.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,911.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,185.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,465.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,855.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,851.06
|
| Rate for Payer: PHCS Commercial |
$5,358.00
|
| Rate for Payer: United Healthcare All Payer |
$4,911.50
|
|
|
BREAST IMP MOD PROFILE 120CC
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD PROFILE 120CC
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD PROFILE 150CC
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD PROFILE 150CC
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD+ PROFILE 158CC
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD+ PROFILE 158CC
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD+ PROFILE 176CC
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD+ PROFILE 176CC
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD PROFILE 180CC
|
Facility
|
IP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
|
BREAST IMP MOD PROFILE 180CC
|
Facility
|
OP
|
$4,062.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.75 |
| Max. Negotiated Rate |
$3,900.00 |
| Rate for Payer: Aetna Commercial |
$3,128.12
|
| Rate for Payer: Anthem Medicaid |
$1,397.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,168.75
|
| Rate for Payer: Cash Price |
$2,031.25
|
| Rate for Payer: Cigna Commercial |
$3,371.88
|
| Rate for Payer: First Health Commercial |
$3,859.38
|
| Rate for Payer: Humana Commercial |
$3,453.12
|
| Rate for Payer: Humana KY Medicaid |
$1,397.09
|
| Rate for Payer: Kentucky WC Medicaid |
$1,411.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,331.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,998.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,218.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,425.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,575.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,046.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,250.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,534.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,803.12
|
| Rate for Payer: PHCS Commercial |
$3,900.00
|
| Rate for Payer: United Healthcare All Payer |
$3,575.00
|
|
