|
CUP RESTORATION ADM 56MM LEFT
|
Facility
|
IP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 56MM LEFT
|
Facility
|
OP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem Medicaid |
$4,260.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Humana KY Medicaid |
$4,260.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,303.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,345.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 56MM RIGHT
|
Facility
|
OP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem Medicaid |
$5,688.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Humana KY Medicaid |
$5,688.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,746.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,802.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 56MM RIGHT
|
Facility
|
IP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 58MM LEFT
|
Facility
|
IP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 58MM LEFT
|
Facility
|
OP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem Medicaid |
$4,260.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Humana KY Medicaid |
$4,260.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,303.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,345.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 58MM RIGHT
|
Facility
|
IP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 58MM RIGHT
|
Facility
|
OP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem Medicaid |
$4,260.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Humana KY Medicaid |
$4,260.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,303.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,345.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 60MM LEFT
|
Facility
|
OP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem Medicaid |
$4,260.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Humana KY Medicaid |
$4,260.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,303.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,345.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 60MM LEFT
|
Facility
|
IP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 60MM RIGHT
|
Facility
|
OP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem Medicaid |
$4,260.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Humana KY Medicaid |
$4,260.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4,303.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,345.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 60MM RIGHT
|
Facility
|
IP
|
$12,388.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,610.50 |
| Max. Negotiated Rate |
$11,892.96 |
| Rate for Payer: Aetna Commercial |
$9,539.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,663.03
|
| Rate for Payer: Cash Price |
$6,194.25
|
| Rate for Payer: Cigna Commercial |
$10,282.46
|
| Rate for Payer: First Health Commercial |
$11,769.08
|
| Rate for Payer: Humana Commercial |
$10,530.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,158.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,142.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,716.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,901.88
|
| Rate for Payer: Ohio Health Group HMO |
$9,291.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,477.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,840.44
|
| Rate for Payer: PHCS Commercial |
$11,892.96
|
| Rate for Payer: United Healthcare All Payer |
$10,901.88
|
|
|
CUP RESTORATION ADM 62MM LEFT
|
Facility
|
OP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem Medicaid |
$5,688.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Humana KY Medicaid |
$5,688.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,746.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,802.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 62MM LEFT
|
Facility
|
IP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 62MM RIGHT
|
Facility
|
OP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem Medicaid |
$5,688.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Humana KY Medicaid |
$5,688.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,746.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,802.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 62MM RIGHT
|
Facility
|
IP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 64MM LEFT
|
Facility
|
OP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem Medicaid |
$5,688.38
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Humana KY Medicaid |
$5,688.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,746.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,802.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 64MM LEFT
|
Facility
|
IP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 64MM RIGHT
|
Facility
|
IP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP RESTORATION ADM 64MM RIGHT
|
Facility
|
OP
|
$16,540.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,150.30 |
| Max. Negotiated Rate |
$15,879.17 |
| Rate for Payer: Aetna Commercial |
$12,736.42
|
| Rate for Payer: Anthem Medicaid |
$5,688.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,901.82
|
| Rate for Payer: Cash Price |
$8,270.40
|
| Rate for Payer: Cigna Commercial |
$13,728.86
|
| Rate for Payer: First Health Commercial |
$15,713.76
|
| Rate for Payer: Humana Commercial |
$14,059.68
|
| Rate for Payer: Humana KY Medicaid |
$5,688.38
|
| Rate for Payer: Kentucky WC Medicaid |
$5,746.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,563.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,207.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,962.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,802.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,555.90
|
| Rate for Payer: Ohio Health Group HMO |
$12,405.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,308.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,150.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,127.65
|
| Rate for Payer: PHCS Commercial |
$15,879.17
|
| Rate for Payer: United Healthcare All Payer |
$14,555.90
|
|
|
CUP TRID 2 CLSTRHOLE HA 46C
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
CUP TRID 2 CLSTRHOLE HA 46C
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
CUP TRID 2 CLSTRHOLE HA 48D
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
CUP TRID 2 CLSTRHOLE HA 48D
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
CUP TRID 2 CLSTRHOLE HA 50D
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
