|
PEG 1 SER A PAT W/WR STD 25
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 25
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 28
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 28
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 31
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 31
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 34
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 34
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 37
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 37
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 40
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR STD 40
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 25
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 25
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 28
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 28
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 31
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 31
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 34
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SER A PAT W/WR THN 34
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SR A PT W/WR THN .37X8.6
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEG 1 SR A PT W/WR THN .37X8.6
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,140.00 |
| Max. Negotiated Rate |
$3,648.00 |
| Rate for Payer: Aetna Commercial |
$2,926.00
|
| Rate for Payer: Anthem Medicaid |
$1,306.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,964.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna Commercial |
$3,154.00
|
| Rate for Payer: First Health Commercial |
$3,610.00
|
| Rate for Payer: Humana Commercial |
$3,230.00
|
| Rate for Payer: Humana KY Medicaid |
$1,306.82
|
| Rate for Payer: Kentucky WC Medicaid |
$1,320.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,116.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,804.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,140.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,333.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,344.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,850.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,040.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,306.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,622.00
|
| Rate for Payer: PHCS Commercial |
$3,648.00
|
| Rate for Payer: United Healthcare All Payer |
$3,344.00
|
|
|
PEGASYS 180MCG/0.5ML KIT
|
Facility
|
OP
|
$5,567.12
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25001168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,670.14 |
| Max. Negotiated Rate |
$5,344.44 |
| Rate for Payer: Aetna Commercial |
$4,286.68
|
| Rate for Payer: Anthem Medicaid |
$1,914.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,342.35
|
| Rate for Payer: Cash Price |
$2,783.56
|
| Rate for Payer: Cigna Commercial |
$4,620.71
|
| Rate for Payer: First Health Commercial |
$5,288.76
|
| Rate for Payer: Humana Commercial |
$4,732.05
|
| Rate for Payer: Humana KY Medicaid |
$1,914.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,934.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,565.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,108.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,670.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,952.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,899.07
|
| Rate for Payer: Ohio Health Group HMO |
$4,175.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,453.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,843.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,841.31
|
| Rate for Payer: PHCS Commercial |
$5,344.44
|
| Rate for Payer: United Healthcare All Payer |
$4,899.07
|
|
|
PEGASYS 180MCG/0.5ML KIT
|
Facility
|
IP
|
$5,567.12
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25001168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,670.14 |
| Max. Negotiated Rate |
$5,344.44 |
| Rate for Payer: Aetna Commercial |
$4,286.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,342.35
|
| Rate for Payer: Cash Price |
$2,783.56
|
| Rate for Payer: Cigna Commercial |
$4,620.71
|
| Rate for Payer: First Health Commercial |
$5,288.76
|
| Rate for Payer: Humana Commercial |
$4,732.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,565.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,108.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,670.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,899.07
|
| Rate for Payer: Ohio Health Group HMO |
$4,175.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,453.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,843.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,841.31
|
| Rate for Payer: PHCS Commercial |
$5,344.44
|
| Rate for Payer: United Healthcare All Payer |
$4,899.07
|
|
|
PEGASYS 180MCG/ML VIAL (1ML)
|
Facility
|
OP
|
$5,567.12
|
|
|
Service Code
|
HCPCS J3590
|
| Hospital Charge Code |
25003656
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,670.14 |
| Max. Negotiated Rate |
$5,344.44 |
| Rate for Payer: Aetna Commercial |
$4,286.68
|
| Rate for Payer: Anthem Medicaid |
$1,914.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,342.35
|
| Rate for Payer: Cash Price |
$2,783.56
|
| Rate for Payer: Cigna Commercial |
$4,620.71
|
| Rate for Payer: First Health Commercial |
$5,288.76
|
| Rate for Payer: Humana Commercial |
$4,732.05
|
| Rate for Payer: Humana KY Medicaid |
$1,914.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,934.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,565.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,108.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,670.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,952.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,899.07
|
| Rate for Payer: Ohio Health Group HMO |
$4,175.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,453.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,843.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,841.31
|
| Rate for Payer: PHCS Commercial |
$5,344.44
|
| Rate for Payer: United Healthcare All Payer |
$4,899.07
|
|
