|
CULTURELLE(LACTOVB RHAMN) CAPS
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
25000500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem Medicaid |
$1.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Humana KY Medicaid |
$1.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
CULTURELLE(LACTOVB RHAMN) CAPS
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 49100036374
|
| Hospital Charge Code |
25000500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$4.56 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.71
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cigna Commercial |
$3.94
|
| Rate for Payer: First Health Commercial |
$4.51
|
| Rate for Payer: Humana Commercial |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.18
|
| Rate for Payer: Ohio Health Group HMO |
$3.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.28
|
| Rate for Payer: PHCS Commercial |
$4.56
|
| Rate for Payer: United Healthcare All Payer |
$4.18
|
|
|
CULTURE OTHR SPECIMN AEROBIC
|
Facility
|
OP
|
$123.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
30001252
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem Medicaid |
$8.62
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.62
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Humana KY Medicaid |
$8.62
|
| Rate for Payer: Humana Medicare Advantage |
$8.62
|
| Rate for Payer: Kentucky WC Medicaid |
$8.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
CULTURE OTHR SPECIMN AEROBIC
|
Facility
|
IP
|
$123.00
|
|
|
Service Code
|
HCPCS 87070
|
| Hospital Charge Code |
30001252
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$118.08 |
| Rate for Payer: Aetna Commercial |
$94.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$98.77
|
| Rate for Payer: Cash Price |
$61.50
|
| Rate for Payer: Cigna Commercial |
$102.09
|
| Rate for Payer: First Health Commercial |
$116.85
|
| Rate for Payer: Humana Commercial |
$104.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$100.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$90.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$36.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$108.24
|
| Rate for Payer: Ohio Health Group HMO |
$92.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$98.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$107.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$84.87
|
| Rate for Payer: PHCS Commercial |
$118.08
|
| Rate for Payer: United Healthcare All Payer |
$108.24
|
|
|
CULTURE REFERRED FOR ID FUNG
|
Facility
|
OP
|
$93.00
|
|
|
Service Code
|
HCPCS 87107
|
| Hospital Charge Code |
30001279
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem Medicaid |
$10.32
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$10.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.68
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$14.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.32
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Humana KY Medicaid |
$10.32
|
| Rate for Payer: Humana Medicare Advantage |
$10.32
|
| Rate for Payer: Kentucky WC Medicaid |
$10.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$12.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
CULTURE REFERRED FOR ID FUNG
|
Facility
|
IP
|
$93.00
|
|
|
Service Code
|
HCPCS 87107
|
| Hospital Charge Code |
30001279
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$27.90 |
| Max. Negotiated Rate |
$89.28 |
| Rate for Payer: Aetna Commercial |
$71.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$74.68
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna Commercial |
$77.19
|
| Rate for Payer: First Health Commercial |
$88.35
|
| Rate for Payer: Humana Commercial |
$79.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$76.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$68.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$81.84
|
| Rate for Payer: Ohio Health Group HMO |
$69.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$74.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$80.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$64.17
|
| Rate for Payer: PHCS Commercial |
$89.28
|
| Rate for Payer: United Healthcare All Payer |
$81.84
|
|
|
CULTURE STOOL
|
Facility
|
IP
|
$156.00
|
|
|
Service Code
|
HCPCS 87045
|
| Hospital Charge Code |
30001248
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$46.80 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$120.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$125.27
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$129.48
|
| Rate for Payer: First Health Commercial |
$148.20
|
| Rate for Payer: Humana Commercial |
$132.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$46.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
| Rate for Payer: Ohio Health Group HMO |
$117.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.64
|
| Rate for Payer: PHCS Commercial |
$149.76
|
| Rate for Payer: United Healthcare All Payer |
$137.28
|
|
|
CULTURE STOOL
|
Professional
|
Both
|
$156.00
|
|
|
Service Code
|
HCPCS 87045
|
| Hospital Charge Code |
30001248
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Ambetter Exchange |
$9.44
|
| Rate for Payer: Buckeye Individual/Medicaid |
$9.44
|
| Rate for Payer: Buckeye Medicare Advantage |
$9.44
|
| Rate for Payer: CareSource Just4Me Medicare |
$11.33
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$8.38
|
| Rate for Payer: Healthspan PPO |
$9.89
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$9.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.44
|
| Rate for Payer: Multiplan PHCS |
$93.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$12.27
|
| Rate for Payer: UHCCP Medicaid |
$54.60
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.66
|
| Rate for Payer: Wellcare Medicare Advantage |
$9.44
|
|
|
CULTURE STOOL
|
Facility
|
OP
|
$156.00
|
|
|
Service Code
|
HCPCS 87045
|
| Hospital Charge Code |
30001248
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$149.76 |
| Rate for Payer: Aetna Commercial |
$120.12
|
| Rate for Payer: Anthem Medicaid |
$9.44
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$125.27
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13.22
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.44
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cash Price |
$78.00
|
| Rate for Payer: Cigna Commercial |
$129.48
|
| Rate for Payer: First Health Commercial |
$148.20
|
| Rate for Payer: Humana Commercial |
$132.60
|
| Rate for Payer: Humana KY Medicaid |
$9.44
|
| Rate for Payer: Humana Medicare Advantage |
$9.44
|
| Rate for Payer: Kentucky WC Medicaid |
$9.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$127.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$115.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$137.28
|
| Rate for Payer: Ohio Health Group HMO |
$117.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$124.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$135.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$107.64
|
| Rate for Payer: PHCS Commercial |
$149.76
|
| Rate for Payer: United Healthcare All Payer |
$137.28
|
|
|
CULTURE URINE QUANT
|
Professional
|
Both
|
$107.00
|
|
|
Service Code
|
HCPCS 87086
|
| Hospital Charge Code |
30001272
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$4.84 |
| Max. Negotiated Rate |
$64.20 |
| Rate for Payer: Aetna Commercial |
$8.77
|
| Rate for Payer: Ambetter Exchange |
$8.07
|
| Rate for Payer: Buckeye Individual/Medicaid |
$8.07
|
| Rate for Payer: Buckeye Medicare Advantage |
$8.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.68
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$7.19
|
| Rate for Payer: Healthspan PPO |
$8.46
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$8.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.07
|
| Rate for Payer: Multiplan PHCS |
$64.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$10.49
|
| Rate for Payer: UHCCP Medicaid |
$37.45
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$4.84
|
| Rate for Payer: Wellcare Medicare Advantage |
$8.07
|
|
|
CULTURE URINE QUANT
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
HCPCS 87086
|
| Hospital Charge Code |
30001272
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$102.72 |
| Rate for Payer: Aetna Commercial |
$82.39
|
| Rate for Payer: Anthem Medicaid |
$8.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$8.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.92
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.30
|
| Rate for Payer: CareSource Just4Me Medicare |
$8.07
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$88.81
|
| Rate for Payer: First Health Commercial |
$101.65
|
| Rate for Payer: Humana Commercial |
$90.95
|
| Rate for Payer: Humana KY Medicaid |
$8.07
|
| Rate for Payer: Humana Medicare Advantage |
$8.07
|
| Rate for Payer: Kentucky WC Medicaid |
$8.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.68
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.16
|
| Rate for Payer: Ohio Health Group HMO |
$80.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$85.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.83
|
| Rate for Payer: PHCS Commercial |
$102.72
|
| Rate for Payer: United Healthcare All Payer |
$94.16
|
|
|
CULTURE URINE QUANT
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
HCPCS 87086
|
| Hospital Charge Code |
30001272
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$32.10 |
| Max. Negotiated Rate |
$102.72 |
| Rate for Payer: Aetna Commercial |
$82.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$85.92
|
| Rate for Payer: Cash Price |
$53.50
|
| Rate for Payer: Cigna Commercial |
$88.81
|
| Rate for Payer: First Health Commercial |
$101.65
|
| Rate for Payer: Humana Commercial |
$90.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$87.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$78.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$32.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$94.16
|
| Rate for Payer: Ohio Health Group HMO |
$80.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$85.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$93.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$73.83
|
| Rate for Payer: PHCS Commercial |
$102.72
|
| Rate for Payer: United Healthcare All Payer |
$94.16
|
|
|
CULTUREWOUND W/ISOLATE & ID
|
Facility
|
IP
|
$10.00
|
|
|
Service Code
|
HCPCS 87075
|
| Hospital Charge Code |
30001256
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.00 |
| Max. Negotiated Rate |
$9.60 |
| Rate for Payer: Aetna Commercial |
$7.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.03
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cigna Commercial |
$8.30
|
| Rate for Payer: First Health Commercial |
$9.50
|
| Rate for Payer: Humana Commercial |
$8.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.80
|
| Rate for Payer: Ohio Health Group HMO |
$7.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$9.60
|
| Rate for Payer: United Healthcare All Payer |
$8.80
|
|
|
CULTUREWOUND W/ISOLATE & ID
|
Facility
|
OP
|
$10.00
|
|
|
Service Code
|
HCPCS 87075
|
| Hospital Charge Code |
30001256
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$13.26 |
| Rate for Payer: Aetna Commercial |
$7.70
|
| Rate for Payer: Anthem Medicaid |
$9.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.03
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$13.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.47
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cash Price |
$5.00
|
| Rate for Payer: Cigna Commercial |
$8.30
|
| Rate for Payer: First Health Commercial |
$9.50
|
| Rate for Payer: Humana Commercial |
$8.50
|
| Rate for Payer: Humana KY Medicaid |
$9.47
|
| Rate for Payer: Humana Medicare Advantage |
$9.47
|
| Rate for Payer: Kentucky WC Medicaid |
$9.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.80
|
| Rate for Payer: Ohio Health Group HMO |
$7.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.90
|
| Rate for Payer: PHCS Commercial |
$9.60
|
| Rate for Payer: United Healthcare All Payer |
$8.80
|
|
|
CUP RESTORATION ADM 46MM LEFT
|
Facility
|
OP
|
$17,083.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,125.08 |
| Max. Negotiated Rate |
$16,400.26 |
| Rate for Payer: Aetna Commercial |
$13,154.37
|
| Rate for Payer: Anthem Medicaid |
$5,875.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,325.21
|
| Rate for Payer: Cash Price |
$8,541.80
|
| Rate for Payer: Cigna Commercial |
$14,179.39
|
| Rate for Payer: First Health Commercial |
$16,229.42
|
| Rate for Payer: Humana Commercial |
$14,521.06
|
| Rate for Payer: Humana KY Medicaid |
$5,875.05
|
| Rate for Payer: Kentucky WC Medicaid |
$5,934.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,008.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,607.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,125.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,992.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,033.57
|
| Rate for Payer: Ohio Health Group HMO |
$12,812.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,666.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,862.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,787.68
|
| Rate for Payer: PHCS Commercial |
$16,400.26
|
| Rate for Payer: United Healthcare All Payer |
$15,033.57
|
|
|
CUP RESTORATION ADM 46MM LEFT
|
Facility
|
IP
|
$17,083.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,125.08 |
| Max. Negotiated Rate |
$16,400.26 |
| Rate for Payer: Aetna Commercial |
$13,154.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,325.21
|
| Rate for Payer: Cash Price |
$8,541.80
|
| Rate for Payer: Cigna Commercial |
$14,179.39
|
| Rate for Payer: First Health Commercial |
$16,229.42
|
| Rate for Payer: Humana Commercial |
$14,521.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,008.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,607.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,125.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,033.57
|
| Rate for Payer: Ohio Health Group HMO |
$12,812.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,666.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,862.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,787.68
|
| Rate for Payer: PHCS Commercial |
$16,400.26
|
| Rate for Payer: United Healthcare All Payer |
$15,033.57
|
|
|
CUP RESTORATION ADM 46MM RIGHT
|
Facility
|
OP
|
$17,083.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,125.08 |
| Max. Negotiated Rate |
$16,400.26 |
| Rate for Payer: Aetna Commercial |
$13,154.37
|
| Rate for Payer: Anthem Medicaid |
$5,875.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,325.21
|
| Rate for Payer: Cash Price |
$8,541.80
|
| Rate for Payer: Cigna Commercial |
$14,179.39
|
| Rate for Payer: First Health Commercial |
$16,229.42
|
| Rate for Payer: Humana Commercial |
$14,521.06
|
| Rate for Payer: Humana KY Medicaid |
$5,875.05
|
| Rate for Payer: Kentucky WC Medicaid |
$5,934.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,008.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,607.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,125.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,992.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,033.57
|
| Rate for Payer: Ohio Health Group HMO |
$12,812.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,666.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,862.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,787.68
|
| Rate for Payer: PHCS Commercial |
$16,400.26
|
| Rate for Payer: United Healthcare All Payer |
$15,033.57
|
|
|
CUP RESTORATION ADM 46MM RIGHT
|
Facility
|
IP
|
$17,083.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,125.08 |
| Max. Negotiated Rate |
$16,400.26 |
| Rate for Payer: Aetna Commercial |
$13,154.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,325.21
|
| Rate for Payer: Cash Price |
$8,541.80
|
| Rate for Payer: Cigna Commercial |
$14,179.39
|
| Rate for Payer: First Health Commercial |
$16,229.42
|
| Rate for Payer: Humana Commercial |
$14,521.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,008.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,607.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,125.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,033.57
|
| Rate for Payer: Ohio Health Group HMO |
$12,812.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,666.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,862.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,787.68
|
| Rate for Payer: PHCS Commercial |
$16,400.26
|
| Rate for Payer: United Healthcare All Payer |
$15,033.57
|
|
|
CUP RESTORATION ADM 48MM LEFT
|
Facility
|
IP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
CUP RESTORATION ADM 48MM LEFT
|
Facility
|
OP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem Medicaid |
$4,346.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Humana KY Medicaid |
$4,346.31
|
| Rate for Payer: Kentucky WC Medicaid |
$4,390.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,433.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
CUP RESTORATION ADM 48MM RIGHT
|
Facility
|
IP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
CUP RESTORATION ADM 48MM RIGHT
|
Facility
|
OP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem Medicaid |
$4,346.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Humana KY Medicaid |
$4,346.31
|
| Rate for Payer: Kentucky WC Medicaid |
$4,390.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,433.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
CUP RESTORATION ADM 50MM LEFT
|
Facility
|
OP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem Medicaid |
$4,346.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Humana KY Medicaid |
$4,346.31
|
| Rate for Payer: Kentucky WC Medicaid |
$4,390.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,433.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
CUP RESTORATION ADM 50MM LEFT
|
Facility
|
IP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
CUP RESTORATION ADM 50MM RIGHT
|
Facility
|
OP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem Medicaid |
$4,346.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Humana KY Medicaid |
$4,346.31
|
| Rate for Payer: Kentucky WC Medicaid |
$4,390.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,433.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
