|
FREEDOM CONSTR HD 36 TI+3
|
Facility
|
OP
|
$10,816.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,406.09 |
| Max. Negotiated Rate |
$10,383.44 |
| Rate for Payer: Aetna Commercial |
$8,328.38
|
| Rate for Payer: Anthem Medicaid |
$3,719.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,436.54
|
| Rate for Payer: Cash Price |
$5,408.04
|
| Rate for Payer: Cigna Commercial |
$8,977.35
|
| Rate for Payer: First Health Commercial |
$10,275.28
|
| Rate for Payer: Humana Commercial |
$9,193.67
|
| Rate for Payer: Humana KY Medicaid |
$3,719.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,757.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,869.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,982.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,794.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,518.15
|
| Rate for Payer: Ohio Health Group HMO |
$8,112.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,163.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,406.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,352.98
|
| Rate for Payer: PHCS Commercial |
$10,383.44
|
| Rate for Payer: United Healthcare All Payer |
$9,518.15
|
|
|
FREEDOM CONSTR HD 36 TI+3
|
Facility
|
IP
|
$10,816.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,406.09 |
| Max. Negotiated Rate |
$10,383.44 |
| Rate for Payer: Aetna Commercial |
$8,328.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,436.54
|
| Rate for Payer: Cash Price |
$5,408.04
|
| Rate for Payer: Cigna Commercial |
$8,977.35
|
| Rate for Payer: First Health Commercial |
$10,275.28
|
| Rate for Payer: Humana Commercial |
$9,193.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,869.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,982.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,518.15
|
| Rate for Payer: Ohio Health Group HMO |
$8,112.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,163.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,406.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,352.98
|
| Rate for Payer: PHCS Commercial |
$10,383.44
|
| Rate for Payer: United Healthcare All Payer |
$9,518.15
|
|
|
FREEDOM CONSTR HD 36 TI+6
|
Facility
|
OP
|
$9,818.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,276.37 |
| Max. Negotiated Rate |
$9,425.49 |
| Rate for Payer: Aetna Commercial |
$7,560.03
|
| Rate for Payer: Anthem Medicaid |
$3,376.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,658.21
|
| Rate for Payer: Cash Price |
$4,909.11
|
| Rate for Payer: Cigna Commercial |
$8,149.12
|
| Rate for Payer: First Health Commercial |
$9,327.31
|
| Rate for Payer: Humana Commercial |
$8,345.49
|
| Rate for Payer: Humana KY Medicaid |
$3,376.49
|
| Rate for Payer: Kentucky WC Medicaid |
$3,410.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,050.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,245.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,945.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,444.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,640.03
|
| Rate for Payer: Ohio Health Group HMO |
$7,363.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,963.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,276.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,043.65
|
| Rate for Payer: PHCS Commercial |
$9,425.49
|
| Rate for Payer: United Healthcare All Payer |
$8,640.03
|
|
|
FREEDOM CONSTR HD 36 TI+6
|
Facility
|
IP
|
$9,818.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,276.37 |
| Max. Negotiated Rate |
$9,425.49 |
| Rate for Payer: Aetna Commercial |
$7,560.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,658.21
|
| Rate for Payer: Cash Price |
$4,909.11
|
| Rate for Payer: Cigna Commercial |
$8,149.12
|
| Rate for Payer: First Health Commercial |
$9,327.31
|
| Rate for Payer: Humana Commercial |
$8,345.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,050.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,245.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,945.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,640.03
|
| Rate for Payer: Ohio Health Group HMO |
$7,363.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,963.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,276.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,043.65
|
| Rate for Payer: PHCS Commercial |
$9,425.49
|
| Rate for Payer: United Healthcare All Payer |
$8,640.03
|
|
|
FREEDOM CONSTR HD 36 TI+9
|
Facility
|
OP
|
$10,816.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,406.09 |
| Max. Negotiated Rate |
$10,383.44 |
| Rate for Payer: Aetna Commercial |
$8,328.38
|
| Rate for Payer: Anthem Medicaid |
$3,719.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,436.54
|
| Rate for Payer: Cash Price |
$5,408.04
|
| Rate for Payer: Cigna Commercial |
$8,977.35
|
| Rate for Payer: First Health Commercial |
$10,275.28
|
| Rate for Payer: Humana Commercial |
$9,193.67
|
| Rate for Payer: Humana KY Medicaid |
$3,719.65
|
| Rate for Payer: Kentucky WC Medicaid |
$3,757.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,869.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,982.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,794.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,518.15
|
| Rate for Payer: Ohio Health Group HMO |
$8,112.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,163.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,406.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,352.98
|
| Rate for Payer: PHCS Commercial |
$10,383.44
|
| Rate for Payer: United Healthcare All Payer |
$9,518.15
|
|
|
FREEDOM CONSTR HD 36 TI+9
|
Facility
|
IP
|
$10,816.08
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,406.09 |
| Max. Negotiated Rate |
$10,383.44 |
| Rate for Payer: Aetna Commercial |
$8,328.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,436.54
|
| Rate for Payer: Cash Price |
$5,408.04
|
| Rate for Payer: Cigna Commercial |
$8,977.35
|
| Rate for Payer: First Health Commercial |
$10,275.28
|
| Rate for Payer: Humana Commercial |
$9,193.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,869.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,982.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,244.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,518.15
|
| Rate for Payer: Ohio Health Group HMO |
$8,112.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,163.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,406.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,352.98
|
| Rate for Payer: PHCS Commercial |
$10,383.44
|
| Rate for Payer: United Healthcare All Payer |
$9,518.15
|
|
|
FREE JEJUNUM FLAP MICROVASC
|
Professional
|
Both
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
76101778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$7,135.00 |
| Rate for Payer: Aetna Commercial |
$6,867.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,135.00
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,870.63
|
| Rate for Payer: Multiplan PHCS |
$4,281.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,994.50
|
| Rate for Payer: UHCCP Medicaid |
$2,497.25
|
|
|
FREE JEJUNUM FLAP MICROVASC
|
Facility
|
OP
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
76101778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$927.55 |
| Max. Negotiated Rate |
$6,849.60 |
| Rate for Payer: Aetna Commercial |
$5,493.95
|
| Rate for Payer: Anthem Medicaid |
$2,453.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.30
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cigna Commercial |
$5,922.05
|
| Rate for Payer: First Health Commercial |
$6,778.25
|
| Rate for Payer: Humana Commercial |
$6,064.75
|
| Rate for Payer: Humana KY Medicaid |
$2,453.73
|
| Rate for Payer: Kentucky WC Medicaid |
$2,478.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,850.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,502.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,278.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,427.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$927.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,211.85
|
| Rate for Payer: PHCS Commercial |
$6,849.60
|
| Rate for Payer: United Healthcare All Payer |
$6,278.80
|
|
|
FREE JEJUNUM FLAP MICROVASC
|
Facility
|
IP
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
76101778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$927.55 |
| Max. Negotiated Rate |
$6,849.60 |
| Rate for Payer: Aetna Commercial |
$5,493.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,565.30
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cigna Commercial |
$5,922.05
|
| Rate for Payer: First Health Commercial |
$6,778.25
|
| Rate for Payer: Humana Commercial |
$6,064.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,850.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,265.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,140.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,278.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,351.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,427.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$927.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,211.85
|
| Rate for Payer: PHCS Commercial |
$6,849.60
|
| Rate for Payer: United Healthcare All Payer |
$6,278.80
|
|
|
FREE JEJUNUM FLAP MICROVASC(P
|
Professional
|
Both
|
$7,135.00
|
|
|
Service Code
|
HCPCS 43496
|
| Hospital Charge Code |
761P1778
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$7,135.00 |
| Rate for Payer: Aetna Commercial |
$6,867.51
|
| Rate for Payer: Buckeye Medicare Advantage |
$7,135.00
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Cash Price |
$3,567.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$6,870.63
|
| Rate for Payer: Multiplan PHCS |
$4,281.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$4,994.50
|
| Rate for Payer: UHCCP Medicaid |
$2,497.25
|
|
|
FREELINK REMOTE CONTROL KIT MR
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
FREELINK REMOTE CONTROL KIT MR
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1787
|
| Hospital Charge Code |
27000083
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
FREE T3
|
Professional
|
Both
|
$139.00
|
|
|
Service Code
|
HCPCS 84481
|
| Hospital Charge Code |
30000543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$139.00 |
| Rate for Payer: Aetna Commercial |
$13.01
|
| Rate for Payer: Buckeye Medicare Advantage |
$139.00
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cigna Commercial |
$14.86
|
| Rate for Payer: Healthspan PPO |
$17.75
|
| Rate for Payer: Multiplan PHCS |
$83.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$97.30
|
| Rate for Payer: UHCCP Medicaid |
$48.65
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$10.16
|
|
|
FREE T3
|
Facility
|
IP
|
$139.00
|
|
|
Service Code
|
HCPCS 84481
|
| Hospital Charge Code |
30000543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.07 |
| Max. Negotiated Rate |
$133.44 |
| Rate for Payer: Aetna Commercial |
$107.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.62
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cigna Commercial |
$115.37
|
| Rate for Payer: First Health Commercial |
$132.05
|
| Rate for Payer: Humana Commercial |
$118.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$102.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$41.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$122.32
|
| Rate for Payer: Ohio Health Group HMO |
$104.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.09
|
| Rate for Payer: PHCS Commercial |
$133.44
|
| Rate for Payer: United Healthcare All Payer |
$122.32
|
|
|
FREE T3
|
Facility
|
OP
|
$139.00
|
|
|
Service Code
|
HCPCS 84481
|
| Hospital Charge Code |
30000543
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.94 |
| Max. Negotiated Rate |
$133.44 |
| Rate for Payer: Aetna Commercial |
$107.03
|
| Rate for Payer: Anthem Medicaid |
$16.94
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$16.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$111.62
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$23.72
|
| Rate for Payer: CareSource Just4Me Medicare |
$16.94
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cash Price |
$69.50
|
| Rate for Payer: Cigna Commercial |
$115.37
|
| Rate for Payer: First Health Commercial |
$132.05
|
| Rate for Payer: Humana Commercial |
$118.15
|
| Rate for Payer: Humana KY Medicaid |
$16.94
|
| Rate for Payer: Humana Medicare Advantage |
$16.94
|
| Rate for Payer: Kentucky WC Medicaid |
$17.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$113.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$102.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$17.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$122.32
|
| Rate for Payer: Ohio Health Group HMO |
$104.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$43.09
|
| Rate for Payer: PHCS Commercial |
$133.44
|
| Rate for Payer: United Healthcare All Payer |
$122.32
|
|
|
FREE T4
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
HCPCS 84439
|
| Hospital Charge Code |
30000528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.02 |
| Max. Negotiated Rate |
$82.56 |
| Rate for Payer: Aetna Commercial |
$66.22
|
| Rate for Payer: Anthem Medicaid |
$9.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$9.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.06
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$12.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$9.02
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$71.38
|
| Rate for Payer: First Health Commercial |
$81.70
|
| Rate for Payer: Humana Commercial |
$73.10
|
| Rate for Payer: Humana KY Medicaid |
$9.02
|
| Rate for Payer: Humana Medicare Advantage |
$9.02
|
| Rate for Payer: Kentucky WC Medicaid |
$9.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.68
|
| Rate for Payer: Ohio Health Group HMO |
$64.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.66
|
| Rate for Payer: PHCS Commercial |
$82.56
|
| Rate for Payer: United Healthcare All Payer |
$75.68
|
|
|
FREE T4
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
HCPCS 84439
|
| Hospital Charge Code |
30000528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.18 |
| Max. Negotiated Rate |
$82.56 |
| Rate for Payer: Aetna Commercial |
$66.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$69.06
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$71.38
|
| Rate for Payer: First Health Commercial |
$81.70
|
| Rate for Payer: Humana Commercial |
$73.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$70.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$25.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$75.68
|
| Rate for Payer: Ohio Health Group HMO |
$64.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$17.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$26.66
|
| Rate for Payer: PHCS Commercial |
$82.56
|
| Rate for Payer: United Healthcare All Payer |
$75.68
|
|
|
FREE T4
|
Professional
|
Both
|
$86.00
|
|
|
Service Code
|
HCPCS 84439
|
| Hospital Charge Code |
30000528
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.41 |
| Max. Negotiated Rate |
$86.00 |
| Rate for Payer: Aetna Commercial |
$14.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$86.00
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cash Price |
$43.00
|
| Rate for Payer: Cigna Commercial |
$7.90
|
| Rate for Payer: Healthspan PPO |
$9.45
|
| Rate for Payer: Multiplan PHCS |
$51.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$60.20
|
| Rate for Payer: UHCCP Medicaid |
$30.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$5.41
|
|
|
FRENECTOMY
|
Facility
|
OP
|
$2,957.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
76101658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.41 |
| Max. Negotiated Rate |
$2,838.72 |
| Rate for Payer: Aetna Commercial |
$2,276.89
|
| Rate for Payer: Anthem Medicaid |
$1,016.91
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,318.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,306.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,846.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,780.37
|
| Rate for Payer: Cash Price |
$1,478.50
|
| Rate for Payer: Cash Price |
$1,478.50
|
| Rate for Payer: Cigna Commercial |
$2,454.31
|
| Rate for Payer: First Health Commercial |
$2,809.15
|
| Rate for Payer: Humana Commercial |
$2,513.45
|
| Rate for Payer: Humana KY Medicaid |
$1,016.91
|
| Rate for Payer: Humana Medicare Advantage |
$1,318.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,027.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,424.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,182.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,037.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,602.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,217.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$591.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$916.67
|
| Rate for Payer: PHCS Commercial |
$2,838.72
|
| Rate for Payer: United Healthcare All Payer |
$2,602.16
|
|
|
FRENECTOMY
|
Professional
|
Both
|
$2,957.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
76101658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.46 |
| Max. Negotiated Rate |
$2,957.00 |
| Rate for Payer: Aetna Commercial |
$211.29
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$102.24
|
| Rate for Payer: Anthem Medicaid |
$101.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$2,957.00
|
| Rate for Payer: Cash Price |
$1,478.50
|
| Rate for Payer: Cash Price |
$1,478.50
|
| Rate for Payer: Cigna Commercial |
$209.73
|
| Rate for Payer: Healthspan PPO |
$278.38
|
| Rate for Payer: Humana Medicaid |
$101.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.49
|
| Rate for Payer: Molina Healthcare Passport |
$101.46
|
| Rate for Payer: Multiplan PHCS |
$1,774.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,069.90
|
| Rate for Payer: UHCCP Medicaid |
$107.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.47
|
|
|
FRENECTOMY
|
Facility
|
IP
|
$2,957.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
76101658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$384.41 |
| Max. Negotiated Rate |
$2,838.72 |
| Rate for Payer: Aetna Commercial |
$2,276.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,306.46
|
| Rate for Payer: Cash Price |
$1,478.50
|
| Rate for Payer: Cigna Commercial |
$2,454.31
|
| Rate for Payer: First Health Commercial |
$2,809.15
|
| Rate for Payer: Humana Commercial |
$2,513.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,424.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,182.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$887.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,602.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,217.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$591.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$384.41
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$916.67
|
| Rate for Payer: PHCS Commercial |
$2,838.72
|
| Rate for Payer: United Healthcare All Payer |
$2,602.16
|
|
|
FRENECTOMY(P
|
Professional
|
Both
|
$450.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
761P1658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$101.46 |
| Max. Negotiated Rate |
$450.00 |
| Rate for Payer: Aetna Commercial |
$211.29
|
| Rate for Payer: Anthem HMO/Medicare Advantage/POS/PPO/Pathway Tiered Hospital/Pathway X Tiered Hospital/Traditional |
$102.24
|
| Rate for Payer: Anthem Medicaid |
$101.46
|
| Rate for Payer: Buckeye Medicare Advantage |
$450.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna Commercial |
$209.73
|
| Rate for Payer: Healthspan PPO |
$278.38
|
| Rate for Payer: Humana Medicaid |
$101.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$190.31
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$103.49
|
| Rate for Payer: Molina Healthcare Passport |
$101.46
|
| Rate for Payer: Multiplan PHCS |
$270.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$315.00
|
| Rate for Payer: UHCCP Medicaid |
$107.35
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$102.47
|
|
|
FRENECTOMY(T
|
Facility
|
OP
|
$2,507.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
761T1658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$325.91 |
| Max. Negotiated Rate |
$2,406.72 |
| Rate for Payer: Aetna Commercial |
$1,930.39
|
| Rate for Payer: Anthem Medicaid |
$862.16
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,318.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,955.46
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$1,846.31
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,780.37
|
| Rate for Payer: Cash Price |
$1,253.50
|
| Rate for Payer: Cash Price |
$1,253.50
|
| Rate for Payer: Cigna Commercial |
$2,080.81
|
| Rate for Payer: First Health Commercial |
$2,381.65
|
| Rate for Payer: Humana Commercial |
$2,130.95
|
| Rate for Payer: Humana KY Medicaid |
$862.16
|
| Rate for Payer: Humana Medicare Advantage |
$1,318.79
|
| Rate for Payer: Kentucky WC Medicaid |
$870.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,055.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,850.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$879.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,206.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,880.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$325.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$777.17
|
| Rate for Payer: PHCS Commercial |
$2,406.72
|
| Rate for Payer: United Healthcare All Payer |
$2,206.16
|
|
|
FRENECTOMY(T
|
Facility
|
IP
|
$2,507.00
|
|
|
Service Code
|
HCPCS 41115
|
| Hospital Charge Code |
761T1658
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$325.91 |
| Max. Negotiated Rate |
$2,406.72 |
| Rate for Payer: Aetna Commercial |
$1,930.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,955.46
|
| Rate for Payer: Cash Price |
$1,253.50
|
| Rate for Payer: Cigna Commercial |
$2,080.81
|
| Rate for Payer: First Health Commercial |
$2,381.65
|
| Rate for Payer: Humana Commercial |
$2,130.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,055.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,850.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$752.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,206.16
|
| Rate for Payer: Ohio Health Group HMO |
$1,880.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$501.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$325.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$777.17
|
| Rate for Payer: PHCS Commercial |
$2,406.72
|
| Rate for Payer: United Healthcare All Payer |
$2,206.16
|
|
|
FRESH FROZEN PLASMA 24H EA UN
|
Facility
|
OP
|
$144.00
|
|
|
Service Code
|
HCPCS P9059
|
| Hospital Charge Code |
38000019
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$138.24 |
| Rate for Payer: Aetna Commercial |
$110.88
|
| Rate for Payer: Anthem Medicaid |
$49.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$65.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$112.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$92.20
|
| Rate for Payer: CareSource Just4Me Medicare |
$88.91
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cash Price |
$72.00
|
| Rate for Payer: Cigna Commercial |
$119.52
|
| Rate for Payer: First Health Commercial |
$136.80
|
| Rate for Payer: Humana Commercial |
$122.40
|
| Rate for Payer: Humana KY Medicaid |
$49.52
|
| Rate for Payer: Humana Medicare Advantage |
$65.86
|
| Rate for Payer: Kentucky WC Medicaid |
$50.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$118.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$106.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$79.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$126.72
|
| Rate for Payer: Ohio Health Group HMO |
$108.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$28.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$18.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$44.64
|
| Rate for Payer: PHCS Commercial |
$138.24
|
| Rate for Payer: United Healthcare All Payer |
$126.72
|
|
