|
INSERT POLCUP PE NON-CEM 43/22
|
Facility
|
OP
|
$4,851.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,455.56 |
| Max. Negotiated Rate |
$4,657.80 |
| Rate for Payer: Aetna Commercial |
$3,735.95
|
| Rate for Payer: Anthem Medicaid |
$1,668.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,784.47
|
| Rate for Payer: Cash Price |
$2,425.94
|
| Rate for Payer: Cigna Commercial |
$4,027.06
|
| Rate for Payer: First Health Commercial |
$4,609.29
|
| Rate for Payer: Humana Commercial |
$4,124.10
|
| Rate for Payer: Humana KY Medicaid |
$1,668.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,685.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,978.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,580.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,455.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,702.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,269.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,638.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,881.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,221.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,347.80
|
| Rate for Payer: PHCS Commercial |
$4,657.80
|
| Rate for Payer: United Healthcare All Payer |
$4,269.65
|
|
|
INSERT POLCUP PE NON-CEM 43/22
|
Facility
|
IP
|
$4,851.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,455.56 |
| Max. Negotiated Rate |
$4,657.80 |
| Rate for Payer: Aetna Commercial |
$3,735.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,784.47
|
| Rate for Payer: Cash Price |
$2,425.94
|
| Rate for Payer: Cigna Commercial |
$4,027.06
|
| Rate for Payer: First Health Commercial |
$4,609.29
|
| Rate for Payer: Humana Commercial |
$4,124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,978.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,580.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,455.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,269.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,638.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,881.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,221.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,347.80
|
| Rate for Payer: PHCS Commercial |
$4,657.80
|
| Rate for Payer: United Healthcare All Payer |
$4,269.65
|
|
|
INSERT POLCUP PE NON-CEM 45/22
|
Facility
|
OP
|
$4,851.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,455.56 |
| Max. Negotiated Rate |
$4,657.80 |
| Rate for Payer: Aetna Commercial |
$3,735.95
|
| Rate for Payer: Anthem Medicaid |
$1,668.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,784.47
|
| Rate for Payer: Cash Price |
$2,425.94
|
| Rate for Payer: Cigna Commercial |
$4,027.06
|
| Rate for Payer: First Health Commercial |
$4,609.29
|
| Rate for Payer: Humana Commercial |
$4,124.10
|
| Rate for Payer: Humana KY Medicaid |
$1,668.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1,685.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,978.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,580.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,455.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,702.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,269.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,638.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,881.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,221.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,347.80
|
| Rate for Payer: PHCS Commercial |
$4,657.80
|
| Rate for Payer: United Healthcare All Payer |
$4,269.65
|
|
|
INSERT POLCUP PE NON-CEM 45/22
|
Facility
|
IP
|
$4,851.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,455.56 |
| Max. Negotiated Rate |
$4,657.80 |
| Rate for Payer: Aetna Commercial |
$3,735.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,784.47
|
| Rate for Payer: Cash Price |
$2,425.94
|
| Rate for Payer: Cigna Commercial |
$4,027.06
|
| Rate for Payer: First Health Commercial |
$4,609.29
|
| Rate for Payer: Humana Commercial |
$4,124.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,978.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,580.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,455.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,269.65
|
| Rate for Payer: Ohio Health Group HMO |
$3,638.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,881.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,221.14
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,347.80
|
| Rate for Payer: PHCS Commercial |
$4,657.80
|
| Rate for Payer: United Healthcare All Payer |
$4,269.65
|
|
|
INSERT POLCUP PE NON-CEM 47/28
|
Facility
|
OP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem Medicaid |
$2,312.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Humana KY Medicaid |
$2,312.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,336.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,359.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 47/28
|
Facility
|
IP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 49/28
|
Facility
|
IP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 49/28
|
Facility
|
OP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem Medicaid |
$2,312.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Humana KY Medicaid |
$2,312.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,336.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,359.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 51/28
|
Facility
|
IP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 51/28
|
Facility
|
OP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem Medicaid |
$1,940.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Humana KY Medicaid |
$1,940.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,960.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,979.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 53/28
|
Facility
|
OP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem Medicaid |
$2,312.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Humana KY Medicaid |
$2,312.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,336.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,359.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 53/28
|
Facility
|
IP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 55/28
|
Facility
|
IP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 55/28
|
Facility
|
OP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem Medicaid |
$1,940.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Humana KY Medicaid |
$1,940.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,960.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,979.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 57/28
|
Facility
|
IP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 57/28
|
Facility
|
OP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem Medicaid |
$1,940.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Humana KY Medicaid |
$1,940.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,960.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,979.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 59/28
|
Facility
|
IP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 59/28
|
Facility
|
OP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem Medicaid |
$2,312.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Humana KY Medicaid |
$2,312.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,336.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,359.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 61/28
|
Facility
|
OP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem Medicaid |
$1,940.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Humana KY Medicaid |
$1,940.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,960.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,979.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 61/28
|
Facility
|
IP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 63/28
|
Facility
|
OP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem Medicaid |
$1,940.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Humana KY Medicaid |
$1,940.99
|
| Rate for Payer: Kentucky WC Medicaid |
$1,960.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,979.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 63/28
|
Facility
|
IP
|
$5,644.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,693.22 |
| Max. Negotiated Rate |
$5,418.30 |
| Rate for Payer: Aetna Commercial |
$4,345.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,402.37
|
| Rate for Payer: Cash Price |
$2,822.03
|
| Rate for Payer: Cigna Commercial |
$4,684.57
|
| Rate for Payer: First Health Commercial |
$5,361.86
|
| Rate for Payer: Humana Commercial |
$4,797.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,628.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,165.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,693.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,966.77
|
| Rate for Payer: Ohio Health Group HMO |
$4,233.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,515.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,910.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,894.40
|
| Rate for Payer: PHCS Commercial |
$5,418.30
|
| Rate for Payer: United Healthcare All Payer |
$4,966.77
|
|
|
INSERT POLCUP PE NON-CEM 65/28
|
Facility
|
OP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem Medicaid |
$2,312.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Humana KY Medicaid |
$2,312.67
|
| Rate for Payer: Kentucky WC Medicaid |
$2,336.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,359.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 65/28
|
Facility
|
IP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
|
INSERT POLCUP PE NON-CEM 67/28
|
Facility
|
IP
|
$6,724.82
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,017.45 |
| Max. Negotiated Rate |
$6,455.83 |
| Rate for Payer: Aetna Commercial |
$5,178.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,245.36
|
| Rate for Payer: Cash Price |
$3,362.41
|
| Rate for Payer: Cigna Commercial |
$5,581.60
|
| Rate for Payer: First Health Commercial |
$6,388.58
|
| Rate for Payer: Humana Commercial |
$5,716.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,514.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,962.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,017.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,917.84
|
| Rate for Payer: Ohio Health Group HMO |
$5,043.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,379.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,850.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,640.13
|
| Rate for Payer: PHCS Commercial |
$6,455.83
|
| Rate for Payer: United Healthcare All Payer |
$5,917.84
|
|
