|
OFFST STDTPR LCK 133FP*6.0 PPS
|
Facility
|
IP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
OFFST STDTPR LCK 133FP*7.0 PPS
|
Facility
|
IP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
OFFST STDTPR LCK 133FP*7.0 PPS
|
Facility
|
OP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem Medicaid |
$5,330.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Humana KY Medicaid |
$5,330.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,384.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,437.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
OFFST STDTPR LCK 133FP*8.0 PPS
|
Facility
|
OP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem Medicaid |
$5,330.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Humana KY Medicaid |
$5,330.45
|
| Rate for Payer: Kentucky WC Medicaid |
$5,384.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,437.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
OFFST STDTPR LCK 133FP*8.0 PPS
|
Facility
|
IP
|
$15,500.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,650.00 |
| Max. Negotiated Rate |
$14,880.00 |
| Rate for Payer: Aetna Commercial |
$11,935.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,090.00
|
| Rate for Payer: Cash Price |
$7,750.00
|
| Rate for Payer: Cigna Commercial |
$12,865.00
|
| Rate for Payer: First Health Commercial |
$14,725.00
|
| Rate for Payer: Humana Commercial |
$13,175.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,710.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,439.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,650.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,640.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,625.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,485.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,695.00
|
| Rate for Payer: PHCS Commercial |
$14,880.00
|
| Rate for Payer: United Healthcare All Payer |
$13,640.00
|
|
|
O-F II ACET SHELL 44MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 44MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 46MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 46MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 48MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 48MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 50MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 50MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 52MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 52MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 54MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 54MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 56MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 56MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 58MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 58MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 60MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 60MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 62MM
|
Facility
|
IP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
|
O-F II ACET SHELL 62MM
|
Facility
|
OP
|
$7,306.27
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,191.88 |
| Max. Negotiated Rate |
$7,014.02 |
| Rate for Payer: Aetna Commercial |
$5,625.83
|
| Rate for Payer: Anthem Medicaid |
$2,512.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,698.89
|
| Rate for Payer: Cash Price |
$3,653.14
|
| Rate for Payer: Cigna Commercial |
$6,064.20
|
| Rate for Payer: First Health Commercial |
$6,940.96
|
| Rate for Payer: Humana Commercial |
$6,210.33
|
| Rate for Payer: Humana KY Medicaid |
$2,512.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,538.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,991.14
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,392.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,191.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,563.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,429.52
|
| Rate for Payer: Ohio Health Group HMO |
$5,479.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,845.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,356.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,041.33
|
| Rate for Payer: PHCS Commercial |
$7,014.02
|
| Rate for Payer: United Healthcare All Payer |
$6,429.52
|
|
