|
EVOLUTN PS INS S6 PLUS 14MM R
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 17MM L
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 17MM L
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 17MM R
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 17MM R
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 20MM L
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 20MM L
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 20MM R
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 20MM R
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 24MM L
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 24MM L
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 24MM R
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN PS INS S6 PLUS 24MM R
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLVE+2 HEAD SZ 20MM 496-H220
|
Facility
|
IP
|
$9,351.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.73 |
| Max. Negotiated Rate |
$8,977.68 |
| Rate for Payer: Aetna Commercial |
$7,200.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,294.36
|
| Rate for Payer: Cash Price |
$4,675.88
|
| Rate for Payer: Cigna Commercial |
$7,761.95
|
| Rate for Payer: First Health Commercial |
$8,884.16
|
| Rate for Payer: Humana Commercial |
$7,948.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,668.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,901.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,229.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,013.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,870.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,215.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,899.04
|
| Rate for Payer: PHCS Commercial |
$8,977.68
|
| Rate for Payer: United Healthcare All Payer |
$8,229.54
|
|
|
EVOLVE+2 HEAD SZ 20MM 496-H220
|
Facility
|
OP
|
$9,351.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.73 |
| Max. Negotiated Rate |
$8,977.68 |
| Rate for Payer: Aetna Commercial |
$7,200.85
|
| Rate for Payer: Anthem Medicaid |
$3,216.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,294.36
|
| Rate for Payer: Cash Price |
$4,675.88
|
| Rate for Payer: Cigna Commercial |
$7,761.95
|
| Rate for Payer: First Health Commercial |
$8,884.16
|
| Rate for Payer: Humana Commercial |
$7,948.99
|
| Rate for Payer: Humana KY Medicaid |
$3,216.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,248.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,668.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,901.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,805.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,280.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,229.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,013.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,870.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,215.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,899.04
|
| Rate for Payer: PHCS Commercial |
$8,977.68
|
| Rate for Payer: United Healthcare All Payer |
$8,229.54
|
|
|
EVOLVE + 2 HEAD SZ 26MM
|
Facility
|
OP
|
$9,351.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.73 |
| Max. Negotiated Rate |
$8,977.68 |
| Rate for Payer: Aetna Commercial |
$7,200.85
|
| Rate for Payer: Anthem Medicaid |
$3,216.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,294.36
|
| Rate for Payer: Cash Price |
$4,675.88
|
| Rate for Payer: Cigna Commercial |
$7,761.95
|
| Rate for Payer: First Health Commercial |
$8,884.16
|
| Rate for Payer: Humana Commercial |
$7,948.99
|
| Rate for Payer: Humana KY Medicaid |
$3,216.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,248.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,668.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,901.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,805.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,280.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,229.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,013.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,870.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,215.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,899.04
|
| Rate for Payer: PHCS Commercial |
$8,977.68
|
| Rate for Payer: United Healthcare All Payer |
$8,229.54
|
|
|
EVOLVE + 2 HEAD SZ 26MM
|
Facility
|
IP
|
$9,351.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,215.73 |
| Max. Negotiated Rate |
$8,977.68 |
| Rate for Payer: Aetna Commercial |
$7,200.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,294.36
|
| Rate for Payer: Cash Price |
$4,675.88
|
| Rate for Payer: Cigna Commercial |
$7,761.95
|
| Rate for Payer: First Health Commercial |
$8,884.16
|
| Rate for Payer: Humana Commercial |
$7,948.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,668.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,901.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,805.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,229.54
|
| Rate for Payer: Ohio Health Group HMO |
$7,013.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,870.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,215.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,899.04
|
| Rate for Payer: PHCS Commercial |
$8,977.68
|
| Rate for Payer: United Healthcare All Payer |
$8,229.54
|
|
|
EVOLVE+4 HEAD SZ 24MM 496-H424
|
Facility
|
IP
|
$9,680.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,258.43 |
| Max. Negotiated Rate |
$9,293.04 |
| Rate for Payer: Aetna Commercial |
$7,453.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,550.60
|
| Rate for Payer: Cash Price |
$4,840.12
|
| Rate for Payer: Cigna Commercial |
$8,034.61
|
| Rate for Payer: First Health Commercial |
$9,196.24
|
| Rate for Payer: Humana Commercial |
$8,228.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,937.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,144.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,904.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,518.62
|
| Rate for Payer: Ohio Health Group HMO |
$7,260.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,936.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,258.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,000.88
|
| Rate for Payer: PHCS Commercial |
$9,293.04
|
| Rate for Payer: United Healthcare All Payer |
$8,518.62
|
|
|
EVOLVE+4 HEAD SZ 24MM 496-H424
|
Facility
|
OP
|
$9,680.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,258.43 |
| Max. Negotiated Rate |
$9,293.04 |
| Rate for Payer: Aetna Commercial |
$7,453.79
|
| Rate for Payer: Anthem Medicaid |
$3,329.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,550.60
|
| Rate for Payer: Cash Price |
$4,840.12
|
| Rate for Payer: Cigna Commercial |
$8,034.61
|
| Rate for Payer: First Health Commercial |
$9,196.24
|
| Rate for Payer: Humana Commercial |
$8,228.21
|
| Rate for Payer: Humana KY Medicaid |
$3,329.04
|
| Rate for Payer: Kentucky WC Medicaid |
$3,362.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,937.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,144.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,904.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,395.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,518.62
|
| Rate for Payer: Ohio Health Group HMO |
$7,260.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,936.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,258.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,000.88
|
| Rate for Payer: PHCS Commercial |
$9,293.04
|
| Rate for Payer: United Healthcare All Payer |
$8,518.62
|
|
|
EVOLVE STEM SZ 7.5MM STD
|
Facility
|
OP
|
$11,483.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.83 |
| Max. Negotiated Rate |
$11,023.97 |
| Rate for Payer: Aetna Commercial |
$8,842.14
|
| Rate for Payer: Anthem Medicaid |
$3,949.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,956.97
|
| Rate for Payer: Cash Price |
$5,741.65
|
| Rate for Payer: Cigna Commercial |
$9,531.14
|
| Rate for Payer: First Health Commercial |
$10,909.14
|
| Rate for Payer: Humana Commercial |
$9,760.80
|
| Rate for Payer: Humana KY Medicaid |
$3,949.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,989.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,416.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,474.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,444.99
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,028.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,105.30
|
| Rate for Payer: Ohio Health Group HMO |
$8,612.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,296.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,492.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,559.82
|
| Rate for Payer: PHCS Commercial |
$11,023.97
|
| Rate for Payer: United Healthcare All Payer |
$10,105.30
|
|
|
EVOLVE STEM SZ 7.5MM STD
|
Facility
|
IP
|
$11,483.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,492.83 |
| Max. Negotiated Rate |
$11,023.97 |
| Rate for Payer: Aetna Commercial |
$8,842.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,956.97
|
| Rate for Payer: Cash Price |
$5,741.65
|
| Rate for Payer: Cigna Commercial |
$9,531.14
|
| Rate for Payer: First Health Commercial |
$10,909.14
|
| Rate for Payer: Humana Commercial |
$9,760.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,416.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,474.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,444.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,105.30
|
| Rate for Payer: Ohio Health Group HMO |
$8,612.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,296.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,492.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,559.82
|
| Rate for Payer: PHCS Commercial |
$11,023.97
|
| Rate for Payer: United Healthcare All Payer |
$10,105.30
|
|
|
Evusheld Injection
|
Facility
|
IP
|
$259.00
|
|
|
Service Code
|
HCPCS M0220
|
| Hospital Charge Code |
77000074
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$248.64 |
| Rate for Payer: Aetna Commercial |
$199.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.02
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$214.97
|
| Rate for Payer: First Health Commercial |
$246.05
|
| Rate for Payer: Humana Commercial |
$220.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$212.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$191.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$77.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$227.92
|
| Rate for Payer: Ohio Health Group HMO |
$194.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.29
|
| Rate for Payer: PHCS Commercial |
$248.64
|
| Rate for Payer: United Healthcare All Payer |
$227.92
|
|
|
Evusheld Injection
|
Facility
|
OP
|
$259.00
|
|
|
Service Code
|
HCPCS M0220
|
| Hospital Charge Code |
77000074
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$33.67 |
| Max. Negotiated Rate |
$248.64 |
| Rate for Payer: Aetna Commercial |
$199.43
|
| Rate for Payer: Anthem Medicaid |
$89.07
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$136.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$202.02
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$191.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$184.40
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cash Price |
$129.50
|
| Rate for Payer: Cigna Commercial |
$214.97
|
| Rate for Payer: First Health Commercial |
$246.05
|
| Rate for Payer: Humana Commercial |
$220.15
|
| Rate for Payer: Humana KY Medicaid |
$89.07
|
| Rate for Payer: Humana Medicare Advantage |
$136.59
|
| Rate for Payer: Kentucky WC Medicaid |
$89.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$212.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$191.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$163.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$90.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$227.92
|
| Rate for Payer: Ohio Health Group HMO |
$194.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$51.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$33.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$80.29
|
| Rate for Payer: PHCS Commercial |
$248.64
|
| Rate for Payer: United Healthcare All Payer |
$227.92
|
|
|
EX ABSCRSS FISTULA SIN TRAC(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 76080
|
| Hospital Charge Code |
320P0183
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$34.59 |
| Max. Negotiated Rate |
$100.00 |
| Rate for Payer: Aetna Commercial |
$97.89
|
| Rate for Payer: Anthem Medicaid |
$52.05
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$98.54
|
| Rate for Payer: Healthspan PPO |
$91.72
|
| Rate for Payer: Humana Medicaid |
$52.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$34.59
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$53.09
|
| Rate for Payer: Molina Healthcare Passport |
$52.05
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$52.57
|
|
|
EX ABSCRSS FISTULA SIN TRAC(T
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
HCPCS 76080
|
| Hospital Charge Code |
320T0183
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$667.88 |
| Rate for Payer: Aetna Commercial |
$509.74
|
| Rate for Payer: Anthem Medicaid |
$227.66
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$477.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$516.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$667.88
|
| Rate for Payer: CareSource Just4Me Medicare |
$644.03
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cash Price |
$331.00
|
| Rate for Payer: Cigna Commercial |
$549.46
|
| Rate for Payer: First Health Commercial |
$628.90
|
| Rate for Payer: Humana Commercial |
$562.70
|
| Rate for Payer: Humana KY Medicaid |
$227.66
|
| Rate for Payer: Humana Medicare Advantage |
$477.06
|
| Rate for Payer: Kentucky WC Medicaid |
$229.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$542.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$488.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$572.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$232.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$582.56
|
| Rate for Payer: Ohio Health Group HMO |
$496.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$132.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$86.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$205.22
|
| Rate for Payer: PHCS Commercial |
$635.52
|
| Rate for Payer: United Healthcare All Payer |
$582.56
|
|
