|
INSERT W/JRNY HI FLEX LK 3-4 9
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLEX LK 5-6 9
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLEX LK 5-6 9
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLEX LK 7-8 9
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLEX LK 7-8 9
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 11
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 11
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 13
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 13
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 15
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 15
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 18
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT W/JRNY HI FLXLK 1-2 18
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
INSERT X 3 #2 RM/LL 12MM
|
Facility
|
IP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,060.70 |
| Max. Negotiated Rate |
$6,594.24 |
| Rate for Payer: Aetna Commercial |
$5,289.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,357.82
|
| Rate for Payer: Cash Price |
$3,434.50
|
| Rate for Payer: Cigna Commercial |
$5,701.27
|
| Rate for Payer: First Health Commercial |
$6,525.55
|
| Rate for Payer: Humana Commercial |
$5,838.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,632.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,069.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,060.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,044.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,151.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,976.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,739.61
|
| Rate for Payer: PHCS Commercial |
$6,594.24
|
| Rate for Payer: United Healthcare All Payer |
$6,044.72
|
|
|
INSERT X 3 #2 RM/LL 12MM
|
Facility
|
OP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,060.70 |
| Max. Negotiated Rate |
$6,594.24 |
| Rate for Payer: Aetna Commercial |
$5,289.13
|
| Rate for Payer: Anthem Medicaid |
$2,362.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,357.82
|
| Rate for Payer: Cash Price |
$3,434.50
|
| Rate for Payer: Cigna Commercial |
$5,701.27
|
| Rate for Payer: First Health Commercial |
$6,525.55
|
| Rate for Payer: Humana Commercial |
$5,838.65
|
| Rate for Payer: Humana KY Medicaid |
$2,362.25
|
| Rate for Payer: Kentucky WC Medicaid |
$2,386.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,632.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,069.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,060.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,409.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,044.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,151.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,976.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,739.61
|
| Rate for Payer: PHCS Commercial |
$6,594.24
|
| Rate for Payer: United Healthcare All Payer |
$6,044.72
|
|
|
INSERT X 3 #3 LM/RL-12MM
|
Facility
|
OP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,060.70 |
| Max. Negotiated Rate |
$6,594.24 |
| Rate for Payer: Aetna Commercial |
$5,289.13
|
| Rate for Payer: Anthem Medicaid |
$2,362.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,357.82
|
| Rate for Payer: Cash Price |
$3,434.50
|
| Rate for Payer: Cigna Commercial |
$5,701.27
|
| Rate for Payer: First Health Commercial |
$6,525.55
|
| Rate for Payer: Humana Commercial |
$5,838.65
|
| Rate for Payer: Humana KY Medicaid |
$2,362.25
|
| Rate for Payer: Kentucky WC Medicaid |
$2,386.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,632.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,069.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,060.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,409.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,044.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,151.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,976.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,739.61
|
| Rate for Payer: PHCS Commercial |
$6,594.24
|
| Rate for Payer: United Healthcare All Payer |
$6,044.72
|
|
|
INSERT X 3 #3 LM/RL-12MM
|
Facility
|
IP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,060.70 |
| Max. Negotiated Rate |
$6,594.24 |
| Rate for Payer: Aetna Commercial |
$5,289.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,357.82
|
| Rate for Payer: Cash Price |
$3,434.50
|
| Rate for Payer: Cigna Commercial |
$5,701.27
|
| Rate for Payer: First Health Commercial |
$6,525.55
|
| Rate for Payer: Humana Commercial |
$5,838.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,632.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,069.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,060.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,044.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,151.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,976.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,739.61
|
| Rate for Payer: PHCS Commercial |
$6,594.24
|
| Rate for Payer: United Healthcare All Payer |
$6,044.72
|
|
|
INSERT X 3 #3 LM/RL-9MM
|
Facility
|
IP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,060.70 |
| Max. Negotiated Rate |
$6,594.24 |
| Rate for Payer: Aetna Commercial |
$5,289.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,357.82
|
| Rate for Payer: Cash Price |
$3,434.50
|
| Rate for Payer: Cigna Commercial |
$5,701.27
|
| Rate for Payer: First Health Commercial |
$6,525.55
|
| Rate for Payer: Humana Commercial |
$5,838.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,632.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,069.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,060.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,044.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,151.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,976.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,739.61
|
| Rate for Payer: PHCS Commercial |
$6,594.24
|
| Rate for Payer: United Healthcare All Payer |
$6,044.72
|
|
|
INSERT X 3 #3 LM/RL-9MM
|
Facility
|
OP
|
$6,869.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,060.70 |
| Max. Negotiated Rate |
$6,594.24 |
| Rate for Payer: Aetna Commercial |
$5,289.13
|
| Rate for Payer: Anthem Medicaid |
$2,362.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,357.82
|
| Rate for Payer: Cash Price |
$3,434.50
|
| Rate for Payer: Cigna Commercial |
$5,701.27
|
| Rate for Payer: First Health Commercial |
$6,525.55
|
| Rate for Payer: Humana Commercial |
$5,838.65
|
| Rate for Payer: Humana KY Medicaid |
$2,362.25
|
| Rate for Payer: Kentucky WC Medicaid |
$2,386.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,632.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,069.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,060.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,409.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,044.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,151.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,495.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,976.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,739.61
|
| Rate for Payer: PHCS Commercial |
$6,594.24
|
| Rate for Payer: United Healthcare All Payer |
$6,044.72
|
|
|
INS EXT HEART AST DEVIMPELLA
|
Facility
|
IP
|
$800.00
|
|
|
Service Code
|
HCPCS 33990
|
| Hospital Charge Code |
76101332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
INS EXT HEART AST DEVIMPELLA
|
Facility
|
IP
|
$3,967.00
|
|
|
Service Code
|
HCPCS 33990
|
| Hospital Charge Code |
48100007
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,190.10 |
| Max. Negotiated Rate |
$3,808.32 |
| Rate for Payer: Aetna Commercial |
$3,054.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,094.26
|
| Rate for Payer: Cash Price |
$1,983.50
|
| Rate for Payer: Cigna Commercial |
$3,292.61
|
| Rate for Payer: First Health Commercial |
$3,768.65
|
| Rate for Payer: Humana Commercial |
$3,371.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,252.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,927.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,490.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,975.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,173.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,451.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,737.23
|
| Rate for Payer: PHCS Commercial |
$3,808.32
|
| Rate for Payer: United Healthcare All Payer |
$3,490.96
|
|
|
INS EXT HEART AST DEVIMPELLA
|
Facility
|
OP
|
$3,967.00
|
|
|
Service Code
|
HCPCS 33990
|
| Hospital Charge Code |
48100007
|
|
Hospital Revenue Code
|
481
|
| Min. Negotiated Rate |
$1,190.10 |
| Max. Negotiated Rate |
$3,808.32 |
| Rate for Payer: Aetna Commercial |
$3,054.59
|
| Rate for Payer: Anthem Medicaid |
$1,364.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,094.26
|
| Rate for Payer: Cash Price |
$1,983.50
|
| Rate for Payer: Cigna Commercial |
$3,292.61
|
| Rate for Payer: First Health Commercial |
$3,768.65
|
| Rate for Payer: Humana Commercial |
$3,371.95
|
| Rate for Payer: Humana KY Medicaid |
$1,364.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,378.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,252.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,927.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,190.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,391.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,490.96
|
| Rate for Payer: Ohio Health Group HMO |
$2,975.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,173.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,451.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,737.23
|
| Rate for Payer: PHCS Commercial |
$3,808.32
|
| Rate for Payer: United Healthcare All Payer |
$3,490.96
|
|
|
INS EXT HEART AST DEVIMPELLA
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 33990
|
| Hospital Charge Code |
76101332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$817.68 |
| Rate for Payer: Ambetter Exchange |
$336.65
|
| Rate for Payer: Anthem Medicaid |
$351.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$336.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$336.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$403.98
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$817.68
|
| Rate for Payer: Healthspan PPO |
$557.84
|
| Rate for Payer: Humana Medicaid |
$351.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$590.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$336.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$358.67
|
| Rate for Payer: Molina Healthcare Passport |
$351.64
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$437.64
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$355.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$336.65
|
|
|
INS EXT HEART AST DEVIMPELLA
|
Facility
|
OP
|
$800.00
|
|
|
Service Code
|
HCPCS 33990
|
| Hospital Charge Code |
76101332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$240.00 |
| Max. Negotiated Rate |
$768.00 |
| Rate for Payer: Aetna Commercial |
$616.00
|
| Rate for Payer: Anthem Medicaid |
$275.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$624.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$664.00
|
| Rate for Payer: First Health Commercial |
$760.00
|
| Rate for Payer: Humana Commercial |
$680.00
|
| Rate for Payer: Humana KY Medicaid |
$275.12
|
| Rate for Payer: Kentucky WC Medicaid |
$277.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$656.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$590.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$280.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$704.00
|
| Rate for Payer: Ohio Health Group HMO |
$600.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$640.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$696.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$552.00
|
| Rate for Payer: PHCS Commercial |
$768.00
|
| Rate for Payer: United Healthcare All Payer |
$704.00
|
|
|
INS EXT HEART AST DEVIMPELLA(P
|
Professional
|
Both
|
$800.00
|
|
|
Service Code
|
HCPCS 33990
|
| Hospital Charge Code |
761P1332
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$280.00 |
| Max. Negotiated Rate |
$817.68 |
| Rate for Payer: Ambetter Exchange |
$336.65
|
| Rate for Payer: Anthem Medicaid |
$351.64
|
| Rate for Payer: Buckeye Individual/Medicaid |
$336.65
|
| Rate for Payer: Buckeye Medicare Advantage |
$336.65
|
| Rate for Payer: CareSource Just4Me Medicare |
$403.98
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cash Price |
$400.00
|
| Rate for Payer: Cigna Commercial |
$817.68
|
| Rate for Payer: Healthspan PPO |
$557.84
|
| Rate for Payer: Humana Medicaid |
$351.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$590.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$336.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$336.65
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$358.67
|
| Rate for Payer: Molina Healthcare Passport |
$351.64
|
| Rate for Payer: Multiplan PHCS |
$480.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$437.64
|
| Rate for Payer: UHCCP Medicaid |
$280.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$355.16
|
| Rate for Payer: Wellcare Medicare Advantage |
$336.65
|
|
