|
IN OFFICE 3 STEP PEEL
|
Professional
|
Both
|
$250.00
|
|
| Hospital Charge Code |
22200324
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$87.50 |
| Max. Negotiated Rate |
$175.00 |
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Multiplan PHCS |
$150.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$175.00
|
| Rate for Payer: UHCCP Medicaid |
$87.50
|
|
|
IN OFFICE STIMULATOR PEEL
|
Professional
|
Both
|
$100.00
|
|
| Hospital Charge Code |
22200323
|
|
Hospital Revenue Code
|
222
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
|
|
IN PACT ADMIRAL 12*40*80
|
Facility
|
OP
|
$13,023.65
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,907.09 |
| Max. Negotiated Rate |
$12,502.70 |
| Rate for Payer: Aetna Commercial |
$10,028.21
|
| Rate for Payer: Anthem Medicaid |
$4,478.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,158.45
|
| Rate for Payer: Cash Price |
$6,511.82
|
| Rate for Payer: Cigna Commercial |
$10,809.63
|
| Rate for Payer: First Health Commercial |
$12,372.47
|
| Rate for Payer: Humana Commercial |
$11,070.10
|
| Rate for Payer: Humana KY Medicaid |
$4,478.83
|
| Rate for Payer: Kentucky WC Medicaid |
$4,524.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,679.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,611.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,907.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,568.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,460.81
|
| Rate for Payer: Ohio Health Group HMO |
$9,767.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,418.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,330.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,986.32
|
| Rate for Payer: PHCS Commercial |
$12,502.70
|
| Rate for Payer: United Healthcare All Payer |
$11,460.81
|
|
|
IN PACT ADMIRAL 12*40*80
|
Facility
|
IP
|
$13,023.65
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,907.09 |
| Max. Negotiated Rate |
$12,502.70 |
| Rate for Payer: Aetna Commercial |
$10,028.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,158.45
|
| Rate for Payer: Cash Price |
$6,511.82
|
| Rate for Payer: Cigna Commercial |
$10,809.63
|
| Rate for Payer: First Health Commercial |
$12,372.47
|
| Rate for Payer: Humana Commercial |
$11,070.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,679.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,611.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,907.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,460.81
|
| Rate for Payer: Ohio Health Group HMO |
$9,767.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,418.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,330.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,986.32
|
| Rate for Payer: PHCS Commercial |
$12,502.70
|
| Rate for Payer: United Healthcare All Payer |
$11,460.81
|
|
|
IN PACT ADMIRAL 4*120*130
|
Facility
|
IP
|
$7,562.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,268.75 |
| Max. Negotiated Rate |
$7,260.00 |
| Rate for Payer: Aetna Commercial |
$5,823.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,898.75
|
| Rate for Payer: Cash Price |
$3,781.25
|
| Rate for Payer: Cigna Commercial |
$6,276.88
|
| Rate for Payer: First Health Commercial |
$7,184.38
|
| Rate for Payer: Humana Commercial |
$6,428.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,201.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,581.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,268.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,655.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,671.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,050.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,579.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,218.12
|
| Rate for Payer: PHCS Commercial |
$7,260.00
|
| Rate for Payer: United Healthcare All Payer |
$6,655.00
|
|
|
IN PACT ADMIRAL 4*120*130
|
Facility
|
OP
|
$7,562.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,268.75 |
| Max. Negotiated Rate |
$7,260.00 |
| Rate for Payer: Aetna Commercial |
$5,823.12
|
| Rate for Payer: Anthem Medicaid |
$2,600.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,898.75
|
| Rate for Payer: Cash Price |
$3,781.25
|
| Rate for Payer: Cigna Commercial |
$6,276.88
|
| Rate for Payer: First Health Commercial |
$7,184.38
|
| Rate for Payer: Humana Commercial |
$6,428.12
|
| Rate for Payer: Humana KY Medicaid |
$2,600.74
|
| Rate for Payer: Kentucky WC Medicaid |
$2,627.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,201.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,581.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,268.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,652.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,655.00
|
| Rate for Payer: Ohio Health Group HMO |
$5,671.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,050.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,579.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,218.12
|
| Rate for Payer: PHCS Commercial |
$7,260.00
|
| Rate for Payer: United Healthcare All Payer |
$6,655.00
|
|
|
IN PACT ADMIRAL 4*150*130
|
Facility
|
IP
|
$8,730.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,619.15 |
| Max. Negotiated Rate |
$8,381.28 |
| Rate for Payer: Aetna Commercial |
$6,722.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,809.79
|
| Rate for Payer: Cash Price |
$4,365.25
|
| Rate for Payer: Cigna Commercial |
$7,246.31
|
| Rate for Payer: First Health Commercial |
$8,293.98
|
| Rate for Payer: Humana Commercial |
$7,420.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,159.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,443.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,619.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,682.84
|
| Rate for Payer: Ohio Health Group HMO |
$6,547.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,984.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,595.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,024.05
|
| Rate for Payer: PHCS Commercial |
$8,381.28
|
| Rate for Payer: United Healthcare All Payer |
$7,682.84
|
|
|
IN PACT ADMIRAL 4*150*130
|
Facility
|
OP
|
$8,730.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,619.15 |
| Max. Negotiated Rate |
$8,381.28 |
| Rate for Payer: Aetna Commercial |
$6,722.48
|
| Rate for Payer: Anthem Medicaid |
$3,002.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,809.79
|
| Rate for Payer: Cash Price |
$4,365.25
|
| Rate for Payer: Cigna Commercial |
$7,246.31
|
| Rate for Payer: First Health Commercial |
$8,293.98
|
| Rate for Payer: Humana Commercial |
$7,420.93
|
| Rate for Payer: Humana KY Medicaid |
$3,002.42
|
| Rate for Payer: Kentucky WC Medicaid |
$3,032.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,159.01
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,443.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,619.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,062.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,682.84
|
| Rate for Payer: Ohio Health Group HMO |
$6,547.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,984.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,595.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,024.05
|
| Rate for Payer: PHCS Commercial |
$8,381.28
|
| Rate for Payer: United Healthcare All Payer |
$7,682.84
|
|
|
IN PACT ADMIRAL 4*200*130
|
Facility
|
IP
|
$11,005.15
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,301.55 |
| Max. Negotiated Rate |
$10,564.94 |
| Rate for Payer: Aetna Commercial |
$8,473.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,584.02
|
| Rate for Payer: Cash Price |
$5,502.58
|
| Rate for Payer: Cigna Commercial |
$9,134.27
|
| Rate for Payer: First Health Commercial |
$10,454.89
|
| Rate for Payer: Humana Commercial |
$9,354.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,024.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,121.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,301.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,684.53
|
| Rate for Payer: Ohio Health Group HMO |
$8,253.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,804.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,574.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,593.55
|
| Rate for Payer: PHCS Commercial |
$10,564.94
|
| Rate for Payer: United Healthcare All Payer |
$9,684.53
|
|
|
IN PACT ADMIRAL 4*200*130
|
Facility
|
OP
|
$11,005.15
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,301.55 |
| Max. Negotiated Rate |
$10,564.94 |
| Rate for Payer: Aetna Commercial |
$8,473.97
|
| Rate for Payer: Anthem Medicaid |
$3,784.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,584.02
|
| Rate for Payer: Cash Price |
$5,502.58
|
| Rate for Payer: Cigna Commercial |
$9,134.27
|
| Rate for Payer: First Health Commercial |
$10,454.89
|
| Rate for Payer: Humana Commercial |
$9,354.38
|
| Rate for Payer: Humana KY Medicaid |
$3,784.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3,823.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,024.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,121.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,301.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,860.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,684.53
|
| Rate for Payer: Ohio Health Group HMO |
$8,253.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,804.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,574.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,593.55
|
| Rate for Payer: PHCS Commercial |
$10,564.94
|
| Rate for Payer: United Healthcare All Payer |
$9,684.53
|
|
|
IN PACT ADMIRAL 4*250*130
|
Facility
|
IP
|
$8,840.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,652.00 |
| Max. Negotiated Rate |
$8,486.40 |
| Rate for Payer: Aetna Commercial |
$6,806.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,895.20
|
| Rate for Payer: Cash Price |
$4,420.00
|
| Rate for Payer: Cigna Commercial |
$7,337.20
|
| Rate for Payer: First Health Commercial |
$8,398.00
|
| Rate for Payer: Humana Commercial |
$7,514.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,248.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,523.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,652.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,779.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,630.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,690.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,099.60
|
| Rate for Payer: PHCS Commercial |
$8,486.40
|
| Rate for Payer: United Healthcare All Payer |
$7,779.20
|
|
|
IN PACT ADMIRAL 4*250*130
|
Facility
|
OP
|
$8,840.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,652.00 |
| Max. Negotiated Rate |
$8,486.40 |
| Rate for Payer: Aetna Commercial |
$6,806.80
|
| Rate for Payer: Anthem Medicaid |
$3,040.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,895.20
|
| Rate for Payer: Cash Price |
$4,420.00
|
| Rate for Payer: Cigna Commercial |
$7,337.20
|
| Rate for Payer: First Health Commercial |
$8,398.00
|
| Rate for Payer: Humana Commercial |
$7,514.00
|
| Rate for Payer: Humana KY Medicaid |
$3,040.08
|
| Rate for Payer: Kentucky WC Medicaid |
$3,071.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,248.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,523.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,652.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,101.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,779.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,630.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,690.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,099.60
|
| Rate for Payer: PHCS Commercial |
$8,486.40
|
| Rate for Payer: United Healthcare All Payer |
$7,779.20
|
|
|
IN PACT ADMIRAL 4*40*130
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
IN PACT ADMIRAL 4*40*130
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
IN PACT ADMIRAL 4*80*130
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
IN PACT ADMIRAL 4*80*130
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
IN PACT ADMIRAL 5*120*130
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
IN PACT ADMIRAL 5*120*130
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
IN PACT ADMIRAL 5*150*130
|
Facility
|
IP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
IN PACT ADMIRAL 5*150*130
|
Facility
|
OP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem Medicaid |
$2,475.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Humana KY Medicaid |
$2,475.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,524.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
IN PACT ADMIRAL 5*200*130
|
Facility
|
OP
|
$11,005.15
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,301.55 |
| Max. Negotiated Rate |
$10,564.94 |
| Rate for Payer: Aetna Commercial |
$8,473.97
|
| Rate for Payer: Anthem Medicaid |
$3,784.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,584.02
|
| Rate for Payer: Cash Price |
$5,502.58
|
| Rate for Payer: Cigna Commercial |
$9,134.27
|
| Rate for Payer: First Health Commercial |
$10,454.89
|
| Rate for Payer: Humana Commercial |
$9,354.38
|
| Rate for Payer: Humana KY Medicaid |
$3,784.67
|
| Rate for Payer: Kentucky WC Medicaid |
$3,823.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,024.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,121.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,301.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,860.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,684.53
|
| Rate for Payer: Ohio Health Group HMO |
$8,253.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,804.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,574.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,593.55
|
| Rate for Payer: PHCS Commercial |
$10,564.94
|
| Rate for Payer: United Healthcare All Payer |
$9,684.53
|
|
|
IN PACT ADMIRAL 5*200*130
|
Facility
|
IP
|
$11,005.15
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3,301.55 |
| Max. Negotiated Rate |
$10,564.94 |
| Rate for Payer: Aetna Commercial |
$8,473.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,584.02
|
| Rate for Payer: Cash Price |
$5,502.58
|
| Rate for Payer: Cigna Commercial |
$9,134.27
|
| Rate for Payer: First Health Commercial |
$10,454.89
|
| Rate for Payer: Humana Commercial |
$9,354.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,024.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,121.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,301.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,684.53
|
| Rate for Payer: Ohio Health Group HMO |
$8,253.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,804.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,574.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,593.55
|
| Rate for Payer: PHCS Commercial |
$10,564.94
|
| Rate for Payer: United Healthcare All Payer |
$9,684.53
|
|
|
IN PACT ADMIRAL 5*250*130
|
Facility
|
OP
|
$8,840.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,652.00 |
| Max. Negotiated Rate |
$8,486.40 |
| Rate for Payer: Aetna Commercial |
$6,806.80
|
| Rate for Payer: Anthem Medicaid |
$3,040.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,895.20
|
| Rate for Payer: Cash Price |
$4,420.00
|
| Rate for Payer: Cigna Commercial |
$7,337.20
|
| Rate for Payer: First Health Commercial |
$8,398.00
|
| Rate for Payer: Humana Commercial |
$7,514.00
|
| Rate for Payer: Humana KY Medicaid |
$3,040.08
|
| Rate for Payer: Kentucky WC Medicaid |
$3,071.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,248.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,523.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,652.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,101.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,779.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,630.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,690.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,099.60
|
| Rate for Payer: PHCS Commercial |
$8,486.40
|
| Rate for Payer: United Healthcare All Payer |
$7,779.20
|
|
|
IN PACT ADMIRAL 5*250*130
|
Facility
|
IP
|
$8,840.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,652.00 |
| Max. Negotiated Rate |
$8,486.40 |
| Rate for Payer: Aetna Commercial |
$6,806.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,895.20
|
| Rate for Payer: Cash Price |
$4,420.00
|
| Rate for Payer: Cigna Commercial |
$7,337.20
|
| Rate for Payer: First Health Commercial |
$8,398.00
|
| Rate for Payer: Humana Commercial |
$7,514.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,248.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,523.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,652.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,779.20
|
| Rate for Payer: Ohio Health Group HMO |
$6,630.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,690.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,099.60
|
| Rate for Payer: PHCS Commercial |
$8,486.40
|
| Rate for Payer: United Healthcare All Payer |
$7,779.20
|
|
|
IN PACT ADMIRAL 5*40*130
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,657.50 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,806.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,812.25
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
