|
DISCOVERY ELBOW ULNA 4*115 R
|
Facility
|
OP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem Medicaid |
$6,342.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Humana KY Medicaid |
$6,342.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,406.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,469.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 4*115 R
|
Facility
|
IP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 4*75 L
|
Facility
|
IP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 4*75 L
|
Facility
|
OP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem Medicaid |
$6,342.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Humana KY Medicaid |
$6,342.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,406.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,469.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 5*115 L
|
Facility
|
IP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 5*115 L
|
Facility
|
OP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem Medicaid |
$6,342.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Humana KY Medicaid |
$6,342.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,406.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,469.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 5*115 R
|
Facility
|
IP
|
$18,093.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,428.11 |
| Max. Negotiated Rate |
$17,369.95 |
| Rate for Payer: Aetna Commercial |
$13,932.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,113.09
|
| Rate for Payer: Cash Price |
$9,046.85
|
| Rate for Payer: Cigna Commercial |
$15,017.77
|
| Rate for Payer: First Health Commercial |
$17,189.01
|
| Rate for Payer: Humana Commercial |
$15,379.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,836.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,353.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,428.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,922.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,570.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,474.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,741.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,484.65
|
| Rate for Payer: PHCS Commercial |
$17,369.95
|
| Rate for Payer: United Healthcare All Payer |
$15,922.46
|
|
|
DISCOVERY ELBOW ULNA 5*115 R
|
Facility
|
OP
|
$18,093.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,428.11 |
| Max. Negotiated Rate |
$17,369.95 |
| Rate for Payer: Aetna Commercial |
$13,932.15
|
| Rate for Payer: Anthem Medicaid |
$6,222.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,113.09
|
| Rate for Payer: Cash Price |
$9,046.85
|
| Rate for Payer: Cigna Commercial |
$15,017.77
|
| Rate for Payer: First Health Commercial |
$17,189.01
|
| Rate for Payer: Humana Commercial |
$15,379.65
|
| Rate for Payer: Humana KY Medicaid |
$6,222.42
|
| Rate for Payer: Kentucky WC Medicaid |
$6,285.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,836.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,353.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,428.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,347.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,922.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,570.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,474.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,741.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,484.65
|
| Rate for Payer: PHCS Commercial |
$17,369.95
|
| Rate for Payer: United Healthcare All Payer |
$15,922.46
|
|
|
DISCOVERY ELBOW ULNA 5*75 L
|
Facility
|
IP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 5*75 L
|
Facility
|
OP
|
$18,441.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,532.45 |
| Max. Negotiated Rate |
$17,703.84 |
| Rate for Payer: Aetna Commercial |
$14,199.95
|
| Rate for Payer: Anthem Medicaid |
$6,342.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,384.37
|
| Rate for Payer: Cash Price |
$9,220.75
|
| Rate for Payer: Cigna Commercial |
$15,306.44
|
| Rate for Payer: First Health Commercial |
$17,519.42
|
| Rate for Payer: Humana Commercial |
$15,675.27
|
| Rate for Payer: Humana KY Medicaid |
$6,342.03
|
| Rate for Payer: Kentucky WC Medicaid |
$6,406.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,122.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,609.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,532.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,469.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,228.52
|
| Rate for Payer: Ohio Health Group HMO |
$13,831.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,753.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,044.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,724.64
|
| Rate for Payer: PHCS Commercial |
$17,703.84
|
| Rate for Payer: United Healthcare All Payer |
$16,228.52
|
|
|
DISCOVERY ELBOW ULNA 5*75 R
|
Facility
|
OP
|
$18,093.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,428.11 |
| Max. Negotiated Rate |
$17,369.95 |
| Rate for Payer: Aetna Commercial |
$13,932.15
|
| Rate for Payer: Anthem Medicaid |
$6,222.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,113.09
|
| Rate for Payer: Cash Price |
$9,046.85
|
| Rate for Payer: Cigna Commercial |
$15,017.77
|
| Rate for Payer: First Health Commercial |
$17,189.01
|
| Rate for Payer: Humana Commercial |
$15,379.65
|
| Rate for Payer: Humana KY Medicaid |
$6,222.42
|
| Rate for Payer: Kentucky WC Medicaid |
$6,285.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,836.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,353.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,428.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,347.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,922.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,570.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,474.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,741.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,484.65
|
| Rate for Payer: PHCS Commercial |
$17,369.95
|
| Rate for Payer: United Healthcare All Payer |
$15,922.46
|
|
|
DISCOVERY ELBOW ULNA 5*75 R
|
Facility
|
IP
|
$18,093.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,428.11 |
| Max. Negotiated Rate |
$17,369.95 |
| Rate for Payer: Aetna Commercial |
$13,932.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,113.09
|
| Rate for Payer: Cash Price |
$9,046.85
|
| Rate for Payer: Cigna Commercial |
$15,017.77
|
| Rate for Payer: First Health Commercial |
$17,189.01
|
| Rate for Payer: Humana Commercial |
$15,379.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,836.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,353.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,428.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,922.46
|
| Rate for Payer: Ohio Health Group HMO |
$13,570.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,474.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,741.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,484.65
|
| Rate for Payer: PHCS Commercial |
$17,369.95
|
| Rate for Payer: United Healthcare All Payer |
$15,922.46
|
|
|
DISCOVERY ELBW HUM CONDYLE SET
|
Facility
|
IP
|
$11,922.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,576.80 |
| Max. Negotiated Rate |
$11,445.74 |
| Rate for Payer: Aetna Commercial |
$9,180.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,299.67
|
| Rate for Payer: Cash Price |
$5,961.32
|
| Rate for Payer: Cigna Commercial |
$9,895.80
|
| Rate for Payer: First Health Commercial |
$11,326.52
|
| Rate for Payer: Humana Commercial |
$10,134.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,776.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,798.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,576.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,491.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,941.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,538.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,372.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,226.63
|
| Rate for Payer: PHCS Commercial |
$11,445.74
|
| Rate for Payer: United Healthcare All Payer |
$10,491.93
|
|
|
DISCOVERY ELBW HUM CONDYLE SET
|
Facility
|
OP
|
$11,922.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,576.80 |
| Max. Negotiated Rate |
$11,445.74 |
| Rate for Payer: Aetna Commercial |
$9,180.44
|
| Rate for Payer: Anthem Medicaid |
$4,100.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,299.67
|
| Rate for Payer: Cash Price |
$5,961.32
|
| Rate for Payer: Cigna Commercial |
$9,895.80
|
| Rate for Payer: First Health Commercial |
$11,326.52
|
| Rate for Payer: Humana Commercial |
$10,134.25
|
| Rate for Payer: Humana KY Medicaid |
$4,100.20
|
| Rate for Payer: Kentucky WC Medicaid |
$4,141.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,776.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,798.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,576.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,182.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,491.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,941.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,538.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,372.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,226.63
|
| Rate for Payer: PHCS Commercial |
$11,445.74
|
| Rate for Payer: United Healthcare All Payer |
$10,491.93
|
|
|
DISCOVISC
|
Facility
|
OP
|
$910.40
|
|
|
Service Code
|
NDC 8065183710
|
| Hospital Charge Code |
25003025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.12 |
| Max. Negotiated Rate |
$873.98 |
| Rate for Payer: Aetna Commercial |
$701.01
|
| Rate for Payer: Anthem Medicaid |
$313.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$710.11
|
| Rate for Payer: Cash Price |
$455.20
|
| Rate for Payer: Cigna Commercial |
$755.63
|
| Rate for Payer: First Health Commercial |
$864.88
|
| Rate for Payer: Humana Commercial |
$773.84
|
| Rate for Payer: Humana KY Medicaid |
$313.09
|
| Rate for Payer: Kentucky WC Medicaid |
$316.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$273.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$319.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$801.15
|
| Rate for Payer: Ohio Health Group HMO |
$682.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$792.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$628.18
|
| Rate for Payer: PHCS Commercial |
$873.98
|
| Rate for Payer: United Healthcare All Payer |
$801.15
|
|
|
DISCOVISC
|
Facility
|
IP
|
$910.40
|
|
|
Service Code
|
NDC 8065183710
|
| Hospital Charge Code |
25003025
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.12 |
| Max. Negotiated Rate |
$873.98 |
| Rate for Payer: Aetna Commercial |
$701.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$710.11
|
| Rate for Payer: Cash Price |
$455.20
|
| Rate for Payer: Cigna Commercial |
$755.63
|
| Rate for Payer: First Health Commercial |
$864.88
|
| Rate for Payer: Humana Commercial |
$773.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$746.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$671.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$273.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$801.15
|
| Rate for Payer: Ohio Health Group HMO |
$682.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$728.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$792.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$628.18
|
| Rate for Payer: PHCS Commercial |
$873.98
|
| Rate for Payer: United Healthcare All Payer |
$801.15
|
|
|
DISPENSE FEE BINAURAL SP
|
Professional
|
Both
|
$269.00
|
|
| Hospital Charge Code |
47000117
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$188.30 |
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Multiplan PHCS |
$161.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.30
|
| Rate for Payer: UHCCP Medicaid |
$94.15
|
|
|
DISPENSE FEE BINAURAL SP
|
Professional
|
Both
|
$541.00
|
|
| Hospital Charge Code |
47000106
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$189.35 |
| Max. Negotiated Rate |
$378.70 |
| Rate for Payer: Cash Price |
$270.50
|
| Rate for Payer: Multiplan PHCS |
$324.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$378.70
|
| Rate for Payer: UHCCP Medicaid |
$189.35
|
|
|
DISPENSE FEE HEAR AID SP
|
Professional
|
Both
|
$269.00
|
|
| Hospital Charge Code |
47000116
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$188.30 |
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Multiplan PHCS |
$161.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.30
|
| Rate for Payer: UHCCP Medicaid |
$94.15
|
|
|
DISPENSE FEE MONAURAL SP
|
Professional
|
Both
|
$269.00
|
|
| Hospital Charge Code |
47000107
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$188.30 |
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Multiplan PHCS |
$161.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.30
|
| Rate for Payer: UHCCP Medicaid |
$94.15
|
|
|
DISPENS FEE BINAURAL
|
Facility
|
IP
|
$580.00
|
|
|
Service Code
|
HCPCS V5160
|
| Hospital Charge Code |
47000047
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$556.80 |
| Rate for Payer: Aetna Commercial |
$446.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$452.40
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$481.40
|
| Rate for Payer: First Health Commercial |
$551.00
|
| Rate for Payer: Humana Commercial |
$493.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$475.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$510.40
|
| Rate for Payer: Ohio Health Group HMO |
$435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$504.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.20
|
| Rate for Payer: PHCS Commercial |
$556.80
|
| Rate for Payer: United Healthcare All Payer |
$510.40
|
|
|
DISPENS FEE BINAURAL
|
Facility
|
OP
|
$580.00
|
|
|
Service Code
|
HCPCS V5160
|
| Hospital Charge Code |
47000047
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$174.00 |
| Max. Negotiated Rate |
$556.80 |
| Rate for Payer: Aetna Commercial |
$446.60
|
| Rate for Payer: Anthem Medicaid |
$199.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$452.40
|
| Rate for Payer: Cash Price |
$290.00
|
| Rate for Payer: Cigna Commercial |
$481.40
|
| Rate for Payer: First Health Commercial |
$551.00
|
| Rate for Payer: Humana Commercial |
$493.00
|
| Rate for Payer: Humana KY Medicaid |
$199.46
|
| Rate for Payer: Kentucky WC Medicaid |
$201.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$475.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$428.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$174.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$203.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$510.40
|
| Rate for Payer: Ohio Health Group HMO |
$435.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$504.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$400.20
|
| Rate for Payer: PHCS Commercial |
$556.80
|
| Rate for Payer: United Healthcare All Payer |
$510.40
|
|
|
DISPENS FEE HEAR-AID BICROS
|
Facility
|
OP
|
$269.00
|
|
|
Service Code
|
HCPCS V5200
|
| Hospital Charge Code |
27000046
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$80.70 |
| Max. Negotiated Rate |
$258.24 |
| Rate for Payer: Aetna Commercial |
$207.13
|
| Rate for Payer: Anthem Medicaid |
$92.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.82
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: First Health Commercial |
$255.55
|
| Rate for Payer: Humana Commercial |
$228.65
|
| Rate for Payer: Humana KY Medicaid |
$92.51
|
| Rate for Payer: Kentucky WC Medicaid |
$93.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$220.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$198.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$236.72
|
| Rate for Payer: Ohio Health Group HMO |
$201.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$215.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$185.61
|
| Rate for Payer: PHCS Commercial |
$258.24
|
| Rate for Payer: United Healthcare All Payer |
$236.72
|
|
|
DISPENS FEE HEAR-AID BICROS
|
Professional
|
Both
|
$269.00
|
|
| Hospital Charge Code |
27000046
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$94.15 |
| Max. Negotiated Rate |
$188.30 |
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Multiplan PHCS |
$161.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$188.30
|
| Rate for Payer: UHCCP Medicaid |
$94.15
|
|
|
DISPENS FEE HEAR-AID BICROS
|
Facility
|
IP
|
$269.00
|
|
|
Service Code
|
HCPCS V5200
|
| Hospital Charge Code |
27000046
|
|
Hospital Revenue Code
|
292
|
| Min. Negotiated Rate |
$80.70 |
| Max. Negotiated Rate |
$258.24 |
| Rate for Payer: Aetna Commercial |
$207.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$209.82
|
| Rate for Payer: Cash Price |
$134.50
|
| Rate for Payer: Cigna Commercial |
$223.27
|
| Rate for Payer: First Health Commercial |
$255.55
|
| Rate for Payer: Humana Commercial |
$228.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$220.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$198.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$80.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$236.72
|
| Rate for Payer: Ohio Health Group HMO |
$201.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$215.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$234.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$185.61
|
| Rate for Payer: PHCS Commercial |
$258.24
|
| Rate for Payer: United Healthcare All Payer |
$236.72
|
|
