|
EXIC SUBCU SKIN LESION LEG ANK
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
76100896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.46 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$556.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$157.46
|
| Rate for Payer: Anthem Medicaid |
$209.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$600.07
|
| Rate for Payer: Healthspan PPO |
$622.06
|
| Rate for Payer: Humana Medicaid |
$209.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$392.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.24
|
| Rate for Payer: Molina Healthcare Passport |
$209.06
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$165.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.15
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Professional
|
Both
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
761P0896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$157.46 |
| Max. Negotiated Rate |
$1,000.00 |
| Rate for Payer: Aetna Commercial |
$556.72
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$157.46
|
| Rate for Payer: Anthem Medicaid |
$209.06
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,000.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$600.07
|
| Rate for Payer: Healthspan PPO |
$622.06
|
| Rate for Payer: Humana Medicaid |
$209.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$392.17
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$213.24
|
| Rate for Payer: Molina Healthcare Passport |
$209.06
|
| Rate for Payer: Multiplan PHCS |
$600.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$700.00
|
| Rate for Payer: UHCCP Medicaid |
$165.33
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$211.15
|
|
|
EXIC SUBCU SKIN LESION LEG ANK
|
Facility
|
IP
|
$1,000.00
|
|
|
Service Code
|
HCPCS 27618
|
| Hospital Charge Code |
76100896
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$130.00 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$770.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$780.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna Commercial |
$830.00
|
| Rate for Payer: First Health Commercial |
$950.00
|
| Rate for Payer: Humana Commercial |
$850.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$820.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$738.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$300.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$880.00
|
| Rate for Payer: Ohio Health Group HMO |
$750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$200.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$130.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$310.00
|
| Rate for Payer: PHCS Commercial |
$960.00
|
| Rate for Payer: United Healthcare All Payer |
$880.00
|
|
|
EXJADE 250MG TAB
|
Facility
|
OP
|
$270.38
|
|
|
Service Code
|
NDC 78046915
|
| Hospital Charge Code |
25000653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.15 |
| Max. Negotiated Rate |
$259.56 |
| Rate for Payer: Aetna Commercial |
$208.19
|
| Rate for Payer: Anthem Medicaid |
$92.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.90
|
| Rate for Payer: Cash Price |
$135.19
|
| Rate for Payer: Cigna Commercial |
$224.42
|
| Rate for Payer: First Health Commercial |
$256.86
|
| Rate for Payer: Humana Commercial |
$229.82
|
| Rate for Payer: Humana KY Medicaid |
$92.98
|
| Rate for Payer: Kentucky WC Medicaid |
$93.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$94.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.93
|
| Rate for Payer: Ohio Health Group HMO |
$202.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.82
|
| Rate for Payer: PHCS Commercial |
$259.56
|
| Rate for Payer: United Healthcare All Payer |
$237.93
|
|
|
EXJADE 250MG TAB
|
Facility
|
IP
|
$270.38
|
|
|
Service Code
|
NDC 78046915
|
| Hospital Charge Code |
25000653
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.15 |
| Max. Negotiated Rate |
$259.56 |
| Rate for Payer: Aetna Commercial |
$208.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$210.90
|
| Rate for Payer: Cash Price |
$135.19
|
| Rate for Payer: Cigna Commercial |
$224.42
|
| Rate for Payer: First Health Commercial |
$256.86
|
| Rate for Payer: Humana Commercial |
$229.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$221.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$199.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$81.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$237.93
|
| Rate for Payer: Ohio Health Group HMO |
$202.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$54.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$35.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$83.82
|
| Rate for Payer: PHCS Commercial |
$259.56
|
| Rate for Payer: United Healthcare All Payer |
$237.93
|
|
|
EXPANDER ALLOX FH SMTH 360-430
|
Facility
|
OP
|
$7,161.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$931.03 |
| Max. Negotiated Rate |
$6,875.28 |
| Rate for Payer: Aetna Commercial |
$5,514.55
|
| Rate for Payer: Anthem Medicaid |
$2,462.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,586.16
|
| Rate for Payer: Cash Price |
$3,580.88
|
| Rate for Payer: Cigna Commercial |
$5,944.25
|
| Rate for Payer: First Health Commercial |
$6,803.66
|
| Rate for Payer: Humana Commercial |
$6,087.49
|
| Rate for Payer: Humana KY Medicaid |
$2,462.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,487.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,872.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,285.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,148.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,512.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,302.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,371.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$931.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,220.14
|
| Rate for Payer: PHCS Commercial |
$6,875.28
|
| Rate for Payer: United Healthcare All Payer |
$6,302.34
|
|
|
EXPANDER ALLOX FH SMTH 360-430
|
Facility
|
IP
|
$7,161.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$931.03 |
| Max. Negotiated Rate |
$6,875.28 |
| Rate for Payer: Aetna Commercial |
$5,514.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,586.16
|
| Rate for Payer: Cash Price |
$3,580.88
|
| Rate for Payer: Cigna Commercial |
$5,944.25
|
| Rate for Payer: First Health Commercial |
$6,803.66
|
| Rate for Payer: Humana Commercial |
$6,087.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,872.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,285.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,148.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,302.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,371.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,432.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$931.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,220.14
|
| Rate for Payer: PHCS Commercial |
$6,875.28
|
| Rate for Payer: United Healthcare All Payer |
$6,302.34
|
|
|
EXPANDER ALLOX FH SMTH 480-575
|
Facility
|
OP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem Medicaid |
$3,467.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Humana KY Medicaid |
$3,467.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX FH SMTH 480-575
|
Facility
|
IP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX FH SMTH 600-720
|
Facility
|
IP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX FH SMTH 600-720
|
Facility
|
OP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem Medicaid |
$3,467.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Humana KY Medicaid |
$3,467.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX MD SMTH 225-280
|
Facility
|
OP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem Medicaid |
$3,467.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Humana KY Medicaid |
$3,467.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX MD SMTH 225-280
|
Facility
|
IP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX MD SMTH 340-420
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
EXPANDER ALLOX MD SMTH 340-420
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
EXPANDER ALLOX MD SMTH 460-550
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
EXPANDER ALLOX MD SMTH 460-550
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
EXPANDER ALLOX MD SMTH 500-600
|
Facility
|
OP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem Medicaid |
$3,222.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Humana KY Medicaid |
$3,222.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,255.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,287.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
EXPANDER ALLOX MD SMTH 500-600
|
Facility
|
IP
|
$9,370.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,218.10 |
| Max. Negotiated Rate |
$8,995.20 |
| Rate for Payer: Aetna Commercial |
$7,214.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,308.60
|
| Rate for Payer: Cash Price |
$4,685.00
|
| Rate for Payer: Cigna Commercial |
$7,777.10
|
| Rate for Payer: First Health Commercial |
$8,901.50
|
| Rate for Payer: Humana Commercial |
$7,964.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,683.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,915.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,811.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,245.60
|
| Rate for Payer: Ohio Health Group HMO |
$7,027.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,874.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,218.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,904.70
|
| Rate for Payer: PHCS Commercial |
$8,995.20
|
| Rate for Payer: United Healthcare All Payer |
$8,245.60
|
|
|
EXPANDER ALLOX MD SMTH 580-690
|
Facility
|
IP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER ALLOX MD SMTH 580-690
|
Facility
|
OP
|
$10,081.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,310.63 |
| Max. Negotiated Rate |
$9,678.48 |
| Rate for Payer: Aetna Commercial |
$7,762.95
|
| Rate for Payer: Anthem Medicaid |
$3,467.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,863.76
|
| Rate for Payer: Cash Price |
$5,040.88
|
| Rate for Payer: Cigna Commercial |
$8,367.85
|
| Rate for Payer: First Health Commercial |
$9,577.66
|
| Rate for Payer: Humana Commercial |
$8,569.49
|
| Rate for Payer: Humana KY Medicaid |
$3,467.11
|
| Rate for Payer: Kentucky WC Medicaid |
$3,502.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,267.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,440.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,024.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,536.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,871.94
|
| Rate for Payer: Ohio Health Group HMO |
$7,561.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,016.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,310.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,125.34
|
| Rate for Payer: PHCS Commercial |
$9,678.48
|
| Rate for Payer: United Healthcare All Payer |
$8,871.94
|
|
|
EXPANDER BREAST MOD HGHT 250CC
|
Facility
|
OP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem Medicaid |
$2,657.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Humana KY Medicaid |
$2,657.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,684.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,710.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
|
EXPANDER BREAST MOD HGHT 250CC
|
Facility
|
IP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
|
EXPANDER BREAST MOD HGHT 300CC
|
Facility
|
OP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem Medicaid |
$2,657.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Humana KY Medicaid |
$2,657.49
|
| Rate for Payer: Kentucky WC Medicaid |
$2,684.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,710.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
|
EXPANDER BREAST MOD HGHT 300CC
|
Facility
|
IP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
