|
GMRS EXTENSION PIECE 30MM
|
Facility
|
OP
|
$12,462.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,620.18 |
| Max. Negotiated Rate |
$11,964.44 |
| Rate for Payer: Aetna Commercial |
$9,596.48
|
| Rate for Payer: Anthem Medicaid |
$4,286.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,721.11
|
| Rate for Payer: Cash Price |
$6,231.48
|
| Rate for Payer: Cigna Commercial |
$10,344.26
|
| Rate for Payer: First Health Commercial |
$11,839.81
|
| Rate for Payer: Humana Commercial |
$10,593.52
|
| Rate for Payer: Humana KY Medicaid |
$4,286.01
|
| Rate for Payer: Kentucky WC Medicaid |
$4,329.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,219.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,197.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,738.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,372.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,967.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,347.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,492.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,620.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,863.52
|
| Rate for Payer: PHCS Commercial |
$11,964.44
|
| Rate for Payer: United Healthcare All Payer |
$10,967.40
|
|
|
GMRS EXTENSION PIECE 30MM
|
Facility
|
IP
|
$12,462.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,620.18 |
| Max. Negotiated Rate |
$11,964.44 |
| Rate for Payer: Aetna Commercial |
$9,596.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,721.11
|
| Rate for Payer: Cash Price |
$6,231.48
|
| Rate for Payer: Cigna Commercial |
$10,344.26
|
| Rate for Payer: First Health Commercial |
$11,839.81
|
| Rate for Payer: Humana Commercial |
$10,593.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,219.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,197.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,738.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,967.40
|
| Rate for Payer: Ohio Health Group HMO |
$9,347.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,492.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,620.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,863.52
|
| Rate for Payer: PHCS Commercial |
$11,964.44
|
| Rate for Payer: United Healthcare All Payer |
$10,967.40
|
|
|
GMRS FLUTD STEM EXT 10MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 10MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 11MM*155MM
|
Facility
|
OP
|
$5,274.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$685.67 |
| Max. Negotiated Rate |
$5,063.42 |
| Rate for Payer: Aetna Commercial |
$4,061.29
|
| Rate for Payer: Anthem Medicaid |
$1,813.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,114.03
|
| Rate for Payer: Cash Price |
$2,637.20
|
| Rate for Payer: Cigna Commercial |
$4,377.75
|
| Rate for Payer: First Health Commercial |
$5,010.68
|
| Rate for Payer: Humana Commercial |
$4,483.24
|
| Rate for Payer: Humana KY Medicaid |
$1,813.87
|
| Rate for Payer: Kentucky WC Medicaid |
$1,832.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,325.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,892.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,850.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,641.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,955.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,054.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$685.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,635.06
|
| Rate for Payer: PHCS Commercial |
$5,063.42
|
| Rate for Payer: United Healthcare All Payer |
$4,641.47
|
|
|
GMRS FLUTD STEM EXT 11MM*155MM
|
Facility
|
IP
|
$5,274.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$685.67 |
| Max. Negotiated Rate |
$5,063.42 |
| Rate for Payer: Aetna Commercial |
$4,061.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,114.03
|
| Rate for Payer: Cash Price |
$2,637.20
|
| Rate for Payer: Cigna Commercial |
$4,377.75
|
| Rate for Payer: First Health Commercial |
$5,010.68
|
| Rate for Payer: Humana Commercial |
$4,483.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,325.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,892.51
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,582.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,641.47
|
| Rate for Payer: Ohio Health Group HMO |
$3,955.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,054.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$685.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,635.06
|
| Rate for Payer: PHCS Commercial |
$5,063.42
|
| Rate for Payer: United Healthcare All Payer |
$4,641.47
|
|
|
GMRS FLUTD STEM EXT 12MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 12MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 13MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 13MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 14MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 14MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 15MM*155MM
|
Facility
|
IP
|
$6,505.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.71 |
| Max. Negotiated Rate |
$6,245.26 |
| Rate for Payer: Aetna Commercial |
$5,009.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,074.27
|
| Rate for Payer: Cash Price |
$3,252.74
|
| Rate for Payer: Cigna Commercial |
$5,399.55
|
| Rate for Payer: First Health Commercial |
$6,180.21
|
| Rate for Payer: Humana Commercial |
$5,529.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,334.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,801.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,951.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,724.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,301.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,016.70
|
| Rate for Payer: PHCS Commercial |
$6,245.26
|
| Rate for Payer: United Healthcare All Payer |
$5,724.82
|
|
|
GMRS FLUTD STEM EXT 15MM*155MM
|
Facility
|
OP
|
$6,505.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.71 |
| Max. Negotiated Rate |
$6,245.26 |
| Rate for Payer: Aetna Commercial |
$5,009.22
|
| Rate for Payer: Anthem Medicaid |
$2,237.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,074.27
|
| Rate for Payer: Cash Price |
$3,252.74
|
| Rate for Payer: Cigna Commercial |
$5,399.55
|
| Rate for Payer: First Health Commercial |
$6,180.21
|
| Rate for Payer: Humana Commercial |
$5,529.66
|
| Rate for Payer: Humana KY Medicaid |
$2,237.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,260.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,334.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,801.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,951.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,282.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,724.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,301.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,016.70
|
| Rate for Payer: PHCS Commercial |
$6,245.26
|
| Rate for Payer: United Healthcare All Payer |
$5,724.82
|
|
|
GMRS FLUTD STEM EXT 16MM*155MM
|
Facility
|
OP
|
$6,505.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.71 |
| Max. Negotiated Rate |
$6,245.26 |
| Rate for Payer: Aetna Commercial |
$5,009.22
|
| Rate for Payer: Anthem Medicaid |
$2,237.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,074.27
|
| Rate for Payer: Cash Price |
$3,252.74
|
| Rate for Payer: Cigna Commercial |
$5,399.55
|
| Rate for Payer: First Health Commercial |
$6,180.21
|
| Rate for Payer: Humana Commercial |
$5,529.66
|
| Rate for Payer: Humana KY Medicaid |
$2,237.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,260.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,334.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,801.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,951.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,282.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,724.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,301.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,016.70
|
| Rate for Payer: PHCS Commercial |
$6,245.26
|
| Rate for Payer: United Healthcare All Payer |
$5,724.82
|
|
|
GMRS FLUTD STEM EXT 16MM*155MM
|
Facility
|
IP
|
$6,505.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.71 |
| Max. Negotiated Rate |
$6,245.26 |
| Rate for Payer: Aetna Commercial |
$5,009.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,074.27
|
| Rate for Payer: Cash Price |
$3,252.74
|
| Rate for Payer: Cigna Commercial |
$5,399.55
|
| Rate for Payer: First Health Commercial |
$6,180.21
|
| Rate for Payer: Humana Commercial |
$5,529.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,334.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,801.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,951.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,724.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,301.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,016.70
|
| Rate for Payer: PHCS Commercial |
$6,245.26
|
| Rate for Payer: United Healthcare All Payer |
$5,724.82
|
|
|
GMRS FLUTD STEM EXT 17MM*155MM
|
Facility
|
OP
|
$6,505.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.71 |
| Max. Negotiated Rate |
$6,245.26 |
| Rate for Payer: Aetna Commercial |
$5,009.22
|
| Rate for Payer: Anthem Medicaid |
$2,237.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,074.27
|
| Rate for Payer: Cash Price |
$3,252.74
|
| Rate for Payer: Cigna Commercial |
$5,399.55
|
| Rate for Payer: First Health Commercial |
$6,180.21
|
| Rate for Payer: Humana Commercial |
$5,529.66
|
| Rate for Payer: Humana KY Medicaid |
$2,237.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,260.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,334.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,801.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,951.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,282.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,724.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,301.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,016.70
|
| Rate for Payer: PHCS Commercial |
$6,245.26
|
| Rate for Payer: United Healthcare All Payer |
$5,724.82
|
|
|
GMRS FLUTD STEM EXT 17MM*155MM
|
Facility
|
IP
|
$6,505.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$845.71 |
| Max. Negotiated Rate |
$6,245.26 |
| Rate for Payer: Aetna Commercial |
$5,009.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,074.27
|
| Rate for Payer: Cash Price |
$3,252.74
|
| Rate for Payer: Cigna Commercial |
$5,399.55
|
| Rate for Payer: First Health Commercial |
$6,180.21
|
| Rate for Payer: Humana Commercial |
$5,529.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,334.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,801.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,951.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,724.82
|
| Rate for Payer: Ohio Health Group HMO |
$4,879.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,301.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$845.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,016.70
|
| Rate for Payer: PHCS Commercial |
$6,245.26
|
| Rate for Payer: United Healthcare All Payer |
$5,724.82
|
|
|
GMRS FLUTD STEM EXT 18MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 18MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 19MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 19MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 21MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 21MM*155MM
|
Facility
|
IP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
|
GMRS FLUTD STEM EXT 23MM*155MM
|
Facility
|
OP
|
$4,994.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$649.27 |
| Max. Negotiated Rate |
$4,794.62 |
| Rate for Payer: Aetna Commercial |
$3,845.69
|
| Rate for Payer: Anthem Medicaid |
$1,717.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,895.63
|
| Rate for Payer: Cash Price |
$2,497.20
|
| Rate for Payer: Cigna Commercial |
$4,145.35
|
| Rate for Payer: First Health Commercial |
$4,744.68
|
| Rate for Payer: Humana Commercial |
$4,245.24
|
| Rate for Payer: Humana KY Medicaid |
$1,717.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,735.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,095.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,685.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,498.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,752.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,395.07
|
| Rate for Payer: Ohio Health Group HMO |
$3,745.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$998.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$649.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,548.26
|
| Rate for Payer: PHCS Commercial |
$4,794.62
|
| Rate for Payer: United Healthcare All Payer |
$4,395.07
|
|
