|
EXPANDER BREAST MOD HGHT 400CC
|
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 400CC
|
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 STY 133P-MV 60
|
Facility
|
IP
|
$8,621.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.83 |
| Max. Negotiated Rate |
$8,276.88 |
| Rate for Payer: Aetna Commercial |
$6,638.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,724.96
|
| Rate for Payer: Cash Price |
$4,310.88
|
| Rate for Payer: Cigna Commercial |
$7,156.05
|
| Rate for Payer: First Health Commercial |
$8,190.66
|
| Rate for Payer: Humana Commercial |
$7,328.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,069.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,362.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,586.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,587.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,466.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,120.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,672.74
|
| Rate for Payer: PHCS Commercial |
$8,276.88
|
| Rate for Payer: United Healthcare All Payer |
$7,587.14
|
|
|
EXPANDER BREAST STY 133P-MV 60
|
Facility
|
OP
|
$8,621.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.83 |
| Max. Negotiated Rate |
$8,276.88 |
| Rate for Payer: Aetna Commercial |
$6,638.75
|
| Rate for Payer: Anthem Medicaid |
$2,965.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,724.96
|
| Rate for Payer: Cash Price |
$4,310.88
|
| Rate for Payer: Cigna Commercial |
$7,156.05
|
| Rate for Payer: First Health Commercial |
$8,190.66
|
| Rate for Payer: Humana Commercial |
$7,328.49
|
| Rate for Payer: Humana KY Medicaid |
$2,965.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,995.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,069.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,362.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,586.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,024.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,587.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,466.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,120.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,672.74
|
| Rate for Payer: PHCS Commercial |
$8,276.88
|
| Rate for Payer: United Healthcare All Payer |
$7,587.14
|
|
|
EXPANDER BREAST TABBED 500CC
|
Facility
|
OP
|
$8,621.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.83 |
| Max. Negotiated Rate |
$8,276.88 |
| Rate for Payer: Aetna Commercial |
$6,638.75
|
| Rate for Payer: Anthem Medicaid |
$2,965.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,724.96
|
| Rate for Payer: Cash Price |
$4,310.88
|
| Rate for Payer: Cigna Commercial |
$7,156.05
|
| Rate for Payer: First Health Commercial |
$8,190.66
|
| Rate for Payer: Humana Commercial |
$7,328.49
|
| Rate for Payer: Humana KY Medicaid |
$2,965.02
|
| Rate for Payer: Kentucky WC Medicaid |
$2,995.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,069.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,362.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,586.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,024.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,587.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,466.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,120.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,672.74
|
| Rate for Payer: PHCS Commercial |
$8,276.88
|
| Rate for Payer: United Healthcare All Payer |
$7,587.14
|
|
|
EXPANDER BREAST TABBED 500CC
|
Facility
|
IP
|
$8,621.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,120.83 |
| Max. Negotiated Rate |
$8,276.88 |
| Rate for Payer: Aetna Commercial |
$6,638.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,724.96
|
| Rate for Payer: Cash Price |
$4,310.88
|
| Rate for Payer: Cigna Commercial |
$7,156.05
|
| Rate for Payer: First Health Commercial |
$8,190.66
|
| Rate for Payer: Humana Commercial |
$7,328.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,069.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,362.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,586.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,587.14
|
| Rate for Payer: Ohio Health Group HMO |
$6,466.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,724.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,120.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,672.74
|
| Rate for Payer: PHCS Commercial |
$8,276.88
|
| Rate for Payer: United Healthcare All Payer |
$7,587.14
|
|
|
EXPANDER BRST SHRT 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 BRST SHRT 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
|
|
|
EXPANDER DERMA SMTH FUL 13*11
|
Facility
|
IP
|
$7,526.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$978.48 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$5,795.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.86
|
| Rate for Payer: Cash Price |
$3,763.38
|
| Rate for Payer: Cigna Commercial |
$6,247.20
|
| Rate for Payer: First Health Commercial |
$7,150.41
|
| Rate for Payer: Humana Commercial |
$6,397.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,505.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$978.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,333.29
|
| Rate for Payer: PHCS Commercial |
$7,225.68
|
| Rate for Payer: United Healthcare All Payer |
$6,623.54
|
|
|
EXPANDER DERMA SMTH FUL 13*11
|
Facility
|
OP
|
$7,526.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$978.48 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$5,795.60
|
| Rate for Payer: Anthem Medicaid |
$2,588.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.86
|
| Rate for Payer: Cash Price |
$3,763.38
|
| Rate for Payer: Cigna Commercial |
$6,247.20
|
| Rate for Payer: First Health Commercial |
$7,150.41
|
| Rate for Payer: Humana Commercial |
$6,397.74
|
| Rate for Payer: Humana KY Medicaid |
$2,588.45
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,505.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$978.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,333.29
|
| Rate for Payer: PHCS Commercial |
$7,225.68
|
| Rate for Payer: United Healthcare All Payer |
$6,623.54
|
|
|
EXPANDER DERMA SMTH FUL 13*12
|
Facility
|
OP
|
$7,526.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$978.48 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$5,795.60
|
| Rate for Payer: Anthem Medicaid |
$2,588.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.86
|
| Rate for Payer: Cash Price |
$3,763.38
|
| Rate for Payer: Cigna Commercial |
$6,247.20
|
| Rate for Payer: First Health Commercial |
$7,150.41
|
| Rate for Payer: Humana Commercial |
$6,397.74
|
| Rate for Payer: Humana KY Medicaid |
$2,588.45
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,505.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$978.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,333.29
|
| Rate for Payer: PHCS Commercial |
$7,225.68
|
| Rate for Payer: United Healthcare All Payer |
$6,623.54
|
|
|
EXPANDER DERMA SMTH FUL 13*12
|
Facility
|
IP
|
$7,526.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$978.48 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$5,795.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.86
|
| Rate for Payer: Cash Price |
$3,763.38
|
| Rate for Payer: Cigna Commercial |
$6,247.20
|
| Rate for Payer: First Health Commercial |
$7,150.41
|
| Rate for Payer: Humana Commercial |
$6,397.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,505.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$978.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,333.29
|
| Rate for Payer: PHCS Commercial |
$7,225.68
|
| Rate for Payer: United Healthcare All Payer |
$6,623.54
|
|
|
EXPANDER SMOOTH 15*11.5 500CC
|
Facility
|
IP
|
$7,526.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$978.48 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$5,795.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.86
|
| Rate for Payer: Cash Price |
$3,763.38
|
| Rate for Payer: Cigna Commercial |
$6,247.20
|
| Rate for Payer: First Health Commercial |
$7,150.41
|
| Rate for Payer: Humana Commercial |
$6,397.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,505.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$978.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,333.29
|
| Rate for Payer: PHCS Commercial |
$7,225.68
|
| Rate for Payer: United Healthcare All Payer |
$6,623.54
|
|
|
EXPANDER SMOOTH 15*11.5 500CC
|
Facility
|
OP
|
$7,526.75
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$978.48 |
| Max. Negotiated Rate |
$7,225.68 |
| Rate for Payer: Aetna Commercial |
$5,795.60
|
| Rate for Payer: Anthem Medicaid |
$2,588.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.86
|
| Rate for Payer: Cash Price |
$3,763.38
|
| Rate for Payer: Cigna Commercial |
$6,247.20
|
| Rate for Payer: First Health Commercial |
$7,150.41
|
| Rate for Payer: Humana Commercial |
$6,397.74
|
| Rate for Payer: Humana KY Medicaid |
$2,588.45
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,258.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,623.54
|
| Rate for Payer: Ohio Health Group HMO |
$5,645.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,505.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$978.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,333.29
|
| Rate for Payer: PHCS Commercial |
$7,225.68
|
| Rate for Payer: United Healthcare All Payer |
$6,623.54
|
|
|
EXPANDER TISSUE MOD W/TABS 500
|
Facility
|
IP
|
$6,632.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.22 |
| Max. Negotiated Rate |
$6,367.20 |
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
EXPANDER TISSUE MOD W/TABS 500
|
Facility
|
OP
|
$6,632.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.22 |
| Max. Negotiated Rate |
$6,367.20 |
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem Medicaid |
$2,280.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Humana KY Medicaid |
$2,280.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,304.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,326.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
EXPANDER TISSUE MOD W/TABS 600
|
Facility
|
OP
|
$6,632.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.22 |
| Max. Negotiated Rate |
$6,367.20 |
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem Medicaid |
$2,280.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Humana KY Medicaid |
$2,280.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,304.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,326.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
EXPANDER TISSUE MOD W/TABS 600
|
Facility
|
IP
|
$6,632.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.22 |
| Max. Negotiated Rate |
$6,367.20 |
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
EXPANDER TISSUE MOD W/TABS 700
|
Facility
|
OP
|
$6,632.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.22 |
| Max. Negotiated Rate |
$6,367.20 |
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem Medicaid |
$2,280.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Humana KY Medicaid |
$2,280.92
|
| Rate for Payer: Kentucky WC Medicaid |
$2,304.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,326.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
EXPANDER TISSUE MOD W/TABS 700
|
Facility
|
IP
|
$6,632.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$862.22 |
| Max. Negotiated Rate |
$6,367.20 |
| Rate for Payer: Aetna Commercial |
$5,107.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,173.35
|
| Rate for Payer: Cash Price |
$3,316.25
|
| Rate for Payer: Cigna Commercial |
$5,504.98
|
| Rate for Payer: First Health Commercial |
$6,300.88
|
| Rate for Payer: Humana Commercial |
$5,637.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,438.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,894.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,989.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,836.60
|
| Rate for Payer: Ohio Health Group HMO |
$4,974.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,326.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$862.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,056.08
|
| Rate for Payer: PHCS Commercial |
$6,367.20
|
| Rate for Payer: United Healthcare All Payer |
$5,836.60
|
|
|
EXPAREL 1.3% 1mg(133mg/10mL)VL
|
Facility
|
OP
|
$1,170.39
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$1,123.57 |
| Rate for Payer: Aetna Commercial |
$901.20
|
| Rate for Payer: Anthem Medicaid |
$402.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.90
|
| Rate for Payer: Cash Price |
$585.20
|
| Rate for Payer: Cigna Commercial |
$971.42
|
| Rate for Payer: First Health Commercial |
$1,111.87
|
| Rate for Payer: Humana Commercial |
$994.83
|
| Rate for Payer: Humana KY Medicaid |
$402.50
|
| Rate for Payer: Kentucky WC Medicaid |
$406.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$410.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.94
|
| Rate for Payer: Ohio Health Group HMO |
$877.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.82
|
| Rate for Payer: PHCS Commercial |
$1,123.57
|
| Rate for Payer: United Healthcare All Payer |
$1,029.94
|
|
|
EXPAREL 1.3% 1mg(133mg/10mL)VL
|
Facility
|
IP
|
$1,170.39
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25004279
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$152.15 |
| Max. Negotiated Rate |
$1,123.57 |
| Rate for Payer: Aetna Commercial |
$901.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$912.90
|
| Rate for Payer: Cash Price |
$585.20
|
| Rate for Payer: Cigna Commercial |
$971.42
|
| Rate for Payer: First Health Commercial |
$1,111.87
|
| Rate for Payer: Humana Commercial |
$994.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$959.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$863.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$351.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,029.94
|
| Rate for Payer: Ohio Health Group HMO |
$877.79
|
| Rate for Payer: Ohio Health Group PPO Differential |
$234.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$152.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$362.82
|
| Rate for Payer: PHCS Commercial |
$1,123.57
|
| Rate for Payer: United Healthcare All Payer |
$1,029.94
|
|
|
EXPAREL 1.3% 1MG(266MG/20ML)VL
|
Facility
|
IP
|
$1,821.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$236.77 |
| Max. Negotiated Rate |
$1,748.43 |
| Rate for Payer: Aetna Commercial |
$1,402.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,420.60
|
| Rate for Payer: Cash Price |
$910.64
|
| Rate for Payer: Cigna Commercial |
$1,511.66
|
| Rate for Payer: First Health Commercial |
$1,730.22
|
| Rate for Payer: Humana Commercial |
$1,548.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,493.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,602.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,365.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$364.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$236.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$564.60
|
| Rate for Payer: PHCS Commercial |
$1,748.43
|
| Rate for Payer: United Healthcare All Payer |
$1,602.73
|
|
|
EXPAREL 1.3% 1MG(266MG/20ML)VL
|
Facility
|
OP
|
$1,821.28
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
25001816
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$236.77 |
| Max. Negotiated Rate |
$1,748.43 |
| Rate for Payer: Aetna Commercial |
$1,402.39
|
| Rate for Payer: Anthem Medicaid |
$626.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,420.60
|
| Rate for Payer: Cash Price |
$910.64
|
| Rate for Payer: Cigna Commercial |
$1,511.66
|
| Rate for Payer: First Health Commercial |
$1,730.22
|
| Rate for Payer: Humana Commercial |
$1,548.09
|
| Rate for Payer: Humana KY Medicaid |
$626.34
|
| Rate for Payer: Kentucky WC Medicaid |
$632.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,493.45
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,344.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$546.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$638.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,602.73
|
| Rate for Payer: Ohio Health Group HMO |
$1,365.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$364.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$236.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$564.60
|
| Rate for Payer: PHCS Commercial |
$1,748.43
|
| Rate for Payer: United Healthcare All Payer |
$1,602.73
|
|
|
EXPLORATION FOREARM
|
Facility
|
IP
|
$1,385.00
|
|
|
Service Code
|
HCPCS 25999
|
| Hospital Charge Code |
76100650
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$180.05 |
| Max. Negotiated Rate |
$1,329.60 |
| Rate for Payer: Aetna Commercial |
$1,066.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,080.30
|
| Rate for Payer: Cash Price |
$692.50
|
| Rate for Payer: Cigna Commercial |
$1,149.55
|
| Rate for Payer: First Health Commercial |
$1,315.75
|
| Rate for Payer: Humana Commercial |
$1,177.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,135.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,022.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$415.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,218.80
|
| Rate for Payer: Ohio Health Group HMO |
$1,038.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$277.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$180.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$429.35
|
| Rate for Payer: PHCS Commercial |
$1,329.60
|
| Rate for Payer: United Healthcare All Payer |
$1,218.80
|
|
