|
PLATE 4.5 TI BD LC-DCP 8H 142M
|
Facility
|
IP
|
$2,211.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.53 |
| Max. Negotiated Rate |
$2,123.30 |
| Rate for Payer: Aetna Commercial |
$1,703.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.18
|
| Rate for Payer: Cash Price |
$1,105.89
|
| Rate for Payer: Cigna Commercial |
$1,835.77
|
| Rate for Payer: First Health Commercial |
$2,101.18
|
| Rate for Payer: Humana Commercial |
$1,880.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,658.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.12
|
| Rate for Payer: PHCS Commercial |
$2,123.30
|
| Rate for Payer: United Healthcare All Payer |
$1,946.36
|
|
|
PLATE 4.5 TI BD LC-DCP 8H 142M
|
Facility
|
OP
|
$2,211.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.53 |
| Max. Negotiated Rate |
$2,123.30 |
| Rate for Payer: Aetna Commercial |
$1,703.06
|
| Rate for Payer: Anthem Medicaid |
$760.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.18
|
| Rate for Payer: Cash Price |
$1,105.89
|
| Rate for Payer: Cigna Commercial |
$1,835.77
|
| Rate for Payer: First Health Commercial |
$2,101.18
|
| Rate for Payer: Humana Commercial |
$1,880.00
|
| Rate for Payer: Humana KY Medicaid |
$760.63
|
| Rate for Payer: Kentucky WC Medicaid |
$768.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$775.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,658.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.12
|
| Rate for Payer: PHCS Commercial |
$2,123.30
|
| Rate for Payer: United Healthcare All Payer |
$1,946.36
|
|
|
PLATE 4.5 TI BD LC-DCP 9H 160M
|
Facility
|
IP
|
$2,211.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.53 |
| Max. Negotiated Rate |
$2,123.30 |
| Rate for Payer: Aetna Commercial |
$1,703.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.18
|
| Rate for Payer: Cash Price |
$1,105.89
|
| Rate for Payer: Cigna Commercial |
$1,835.77
|
| Rate for Payer: First Health Commercial |
$2,101.18
|
| Rate for Payer: Humana Commercial |
$1,880.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,658.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.12
|
| Rate for Payer: PHCS Commercial |
$2,123.30
|
| Rate for Payer: United Healthcare All Payer |
$1,946.36
|
|
|
PLATE 4.5 TI BD LC-DCP 9H 160M
|
Facility
|
OP
|
$2,211.77
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$663.53 |
| Max. Negotiated Rate |
$2,123.30 |
| Rate for Payer: Aetna Commercial |
$1,703.06
|
| Rate for Payer: Anthem Medicaid |
$760.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,725.18
|
| Rate for Payer: Cash Price |
$1,105.89
|
| Rate for Payer: Cigna Commercial |
$1,835.77
|
| Rate for Payer: First Health Commercial |
$2,101.18
|
| Rate for Payer: Humana Commercial |
$1,880.00
|
| Rate for Payer: Humana KY Medicaid |
$760.63
|
| Rate for Payer: Kentucky WC Medicaid |
$768.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,813.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,632.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$663.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$775.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,946.36
|
| Rate for Payer: Ohio Health Group HMO |
$1,658.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,769.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,924.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,526.12
|
| Rate for Payer: PHCS Commercial |
$2,123.30
|
| Rate for Payer: United Healthcare All Payer |
$1,946.36
|
|
|
PLATE 4.5 TI LC-DCP 10H 178MM
|
Facility
|
OP
|
$2,024.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.34 |
| Max. Negotiated Rate |
$1,943.49 |
| Rate for Payer: Aetna Commercial |
$1,558.84
|
| Rate for Payer: Anthem Medicaid |
$696.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.09
|
| Rate for Payer: Cash Price |
$1,012.24
|
| Rate for Payer: Cigna Commercial |
$1,680.31
|
| Rate for Payer: First Health Commercial |
$1,923.25
|
| Rate for Payer: Humana Commercial |
$1,720.80
|
| Rate for Payer: Humana KY Medicaid |
$696.22
|
| Rate for Payer: Kentucky WC Medicaid |
$703.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,781.53
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,619.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,396.88
|
| Rate for Payer: PHCS Commercial |
$1,943.49
|
| Rate for Payer: United Healthcare All Payer |
$1,781.53
|
|
|
PLATE 4.5 TI LC-DCP 10H 178MM
|
Facility
|
IP
|
$2,024.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.34 |
| Max. Negotiated Rate |
$1,943.49 |
| Rate for Payer: Aetna Commercial |
$1,558.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.09
|
| Rate for Payer: Cash Price |
$1,012.24
|
| Rate for Payer: Cigna Commercial |
$1,680.31
|
| Rate for Payer: First Health Commercial |
$1,923.25
|
| Rate for Payer: Humana Commercial |
$1,720.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,781.53
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,619.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,396.88
|
| Rate for Payer: PHCS Commercial |
$1,943.49
|
| Rate for Payer: United Healthcare All Payer |
$1,781.53
|
|
|
PLATE 4.5 TI LC-DCP 11H 196MM
|
Facility
|
IP
|
$2,024.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.34 |
| Max. Negotiated Rate |
$1,943.49 |
| Rate for Payer: Aetna Commercial |
$1,558.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.09
|
| Rate for Payer: Cash Price |
$1,012.24
|
| Rate for Payer: Cigna Commercial |
$1,680.31
|
| Rate for Payer: First Health Commercial |
$1,923.25
|
| Rate for Payer: Humana Commercial |
$1,720.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,781.53
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,619.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,396.88
|
| Rate for Payer: PHCS Commercial |
$1,943.49
|
| Rate for Payer: United Healthcare All Payer |
$1,781.53
|
|
|
PLATE 4.5 TI LC-DCP 11H 196MM
|
Facility
|
OP
|
$2,024.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.34 |
| Max. Negotiated Rate |
$1,943.49 |
| Rate for Payer: Aetna Commercial |
$1,558.84
|
| Rate for Payer: Anthem Medicaid |
$696.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.09
|
| Rate for Payer: Cash Price |
$1,012.24
|
| Rate for Payer: Cigna Commercial |
$1,680.31
|
| Rate for Payer: First Health Commercial |
$1,923.25
|
| Rate for Payer: Humana Commercial |
$1,720.80
|
| Rate for Payer: Humana KY Medicaid |
$696.22
|
| Rate for Payer: Kentucky WC Medicaid |
$703.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,781.53
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,619.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,396.88
|
| Rate for Payer: PHCS Commercial |
$1,943.49
|
| Rate for Payer: United Healthcare All Payer |
$1,781.53
|
|
|
PLATE 4.5 TI LC-DCP 12H 214MM
|
Facility
|
IP
|
$2,024.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.34 |
| Max. Negotiated Rate |
$1,943.49 |
| Rate for Payer: Aetna Commercial |
$1,558.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.09
|
| Rate for Payer: Cash Price |
$1,012.24
|
| Rate for Payer: Cigna Commercial |
$1,680.31
|
| Rate for Payer: First Health Commercial |
$1,923.25
|
| Rate for Payer: Humana Commercial |
$1,720.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,781.53
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,619.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,396.88
|
| Rate for Payer: PHCS Commercial |
$1,943.49
|
| Rate for Payer: United Healthcare All Payer |
$1,781.53
|
|
|
PLATE 4.5 TI LC-DCP 12H 214MM
|
Facility
|
OP
|
$2,024.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$607.34 |
| Max. Negotiated Rate |
$1,943.49 |
| Rate for Payer: Aetna Commercial |
$1,558.84
|
| Rate for Payer: Anthem Medicaid |
$696.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,579.09
|
| Rate for Payer: Cash Price |
$1,012.24
|
| Rate for Payer: Cigna Commercial |
$1,680.31
|
| Rate for Payer: First Health Commercial |
$1,923.25
|
| Rate for Payer: Humana Commercial |
$1,720.80
|
| Rate for Payer: Humana KY Medicaid |
$696.22
|
| Rate for Payer: Kentucky WC Medicaid |
$703.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,660.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,494.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$607.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$710.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,781.53
|
| Rate for Payer: Ohio Health Group HMO |
$1,518.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,619.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,761.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,396.88
|
| Rate for Payer: PHCS Commercial |
$1,943.49
|
| Rate for Payer: United Healthcare All Payer |
$1,781.53
|
|
|
PLATE 4.5 TI LC-DCP 2H 34MM
|
Facility
|
IP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 2H 34MM
|
Facility
|
OP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem Medicaid |
$636.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Humana KY Medicaid |
$636.66
|
| Rate for Payer: Kentucky WC Medicaid |
$643.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 3H 52MM
|
Facility
|
IP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 3H 52MM
|
Facility
|
OP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem Medicaid |
$636.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Humana KY Medicaid |
$636.66
|
| Rate for Payer: Kentucky WC Medicaid |
$643.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 4H 70MM
|
Facility
|
IP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 4H 70MM
|
Facility
|
OP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem Medicaid |
$636.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Humana KY Medicaid |
$636.66
|
| Rate for Payer: Kentucky WC Medicaid |
$643.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 5H 88MM
|
Facility
|
OP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem Medicaid |
$636.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Humana KY Medicaid |
$636.66
|
| Rate for Payer: Kentucky WC Medicaid |
$643.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 5H 88MM
|
Facility
|
IP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 6H 106MM
|
Facility
|
IP
|
$1,539.26
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$461.78 |
| Max. Negotiated Rate |
$1,477.69 |
| Rate for Payer: Aetna Commercial |
$1,185.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,200.62
|
| Rate for Payer: Cash Price |
$769.63
|
| Rate for Payer: Cigna Commercial |
$1,277.59
|
| Rate for Payer: First Health Commercial |
$1,462.30
|
| Rate for Payer: Humana Commercial |
$1,308.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,262.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,135.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$461.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,354.55
|
| Rate for Payer: Ohio Health Group HMO |
$1,154.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,231.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,339.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,062.09
|
| Rate for Payer: PHCS Commercial |
$1,477.69
|
| Rate for Payer: United Healthcare All Payer |
$1,354.55
|
|
|
PLATE 4.5 TI LC-DCP 6H 106MM
|
Facility
|
OP
|
$1,539.26
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$461.78 |
| Max. Negotiated Rate |
$1,477.69 |
| Rate for Payer: Aetna Commercial |
$1,185.23
|
| Rate for Payer: Anthem Medicaid |
$529.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,200.62
|
| Rate for Payer: Cash Price |
$769.63
|
| Rate for Payer: Cigna Commercial |
$1,277.59
|
| Rate for Payer: First Health Commercial |
$1,462.30
|
| Rate for Payer: Humana Commercial |
$1,308.37
|
| Rate for Payer: Humana KY Medicaid |
$529.35
|
| Rate for Payer: Kentucky WC Medicaid |
$534.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,262.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,135.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$461.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$539.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,354.55
|
| Rate for Payer: Ohio Health Group HMO |
$1,154.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,231.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,339.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,062.09
|
| Rate for Payer: PHCS Commercial |
$1,477.69
|
| Rate for Payer: United Healthcare All Payer |
$1,354.55
|
|
|
PLATE 4.5 TI LC-DCP 7H 124MM
|
Facility
|
OP
|
$1,560.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.14 |
| Max. Negotiated Rate |
$1,498.05 |
| Rate for Payer: Aetna Commercial |
$1,201.56
|
| Rate for Payer: Anthem Medicaid |
$536.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,217.17
|
| Rate for Payer: Cash Price |
$780.23
|
| Rate for Payer: Cigna Commercial |
$1,295.19
|
| Rate for Payer: First Health Commercial |
$1,482.45
|
| Rate for Payer: Humana Commercial |
$1,326.40
|
| Rate for Payer: Humana KY Medicaid |
$536.65
|
| Rate for Payer: Kentucky WC Medicaid |
$542.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,279.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,151.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$547.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,373.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,170.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,248.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,357.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,076.72
|
| Rate for Payer: PHCS Commercial |
$1,498.05
|
| Rate for Payer: United Healthcare All Payer |
$1,373.21
|
|
|
PLATE 4.5 TI LC-DCP 7H 124MM
|
Facility
|
IP
|
$1,560.47
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.14 |
| Max. Negotiated Rate |
$1,498.05 |
| Rate for Payer: Aetna Commercial |
$1,201.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,217.17
|
| Rate for Payer: Cash Price |
$780.23
|
| Rate for Payer: Cigna Commercial |
$1,295.19
|
| Rate for Payer: First Health Commercial |
$1,482.45
|
| Rate for Payer: Humana Commercial |
$1,326.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,279.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,151.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$468.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,373.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,170.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,248.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,357.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,076.72
|
| Rate for Payer: PHCS Commercial |
$1,498.05
|
| Rate for Payer: United Healthcare All Payer |
$1,373.21
|
|
|
PLATE 4.5 TI LC-DCP 8H 142MM
|
Facility
|
OP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem Medicaid |
$636.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Humana KY Medicaid |
$636.66
|
| Rate for Payer: Kentucky WC Medicaid |
$643.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 8H 142MM
|
Facility
|
IP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
|
PLATE 4.5 TI LC-DCP 9H 160MM
|
Facility
|
OP
|
$1,851.30
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$555.39 |
| Max. Negotiated Rate |
$1,777.25 |
| Rate for Payer: Aetna Commercial |
$1,425.50
|
| Rate for Payer: Anthem Medicaid |
$636.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,444.01
|
| Rate for Payer: Cash Price |
$925.65
|
| Rate for Payer: Cigna Commercial |
$1,536.58
|
| Rate for Payer: First Health Commercial |
$1,758.73
|
| Rate for Payer: Humana Commercial |
$1,573.61
|
| Rate for Payer: Humana KY Medicaid |
$636.66
|
| Rate for Payer: Kentucky WC Medicaid |
$643.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,518.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,366.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$555.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$649.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,629.14
|
| Rate for Payer: Ohio Health Group HMO |
$1,388.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,481.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,610.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,277.40
|
| Rate for Payer: PHCS Commercial |
$1,777.25
|
| Rate for Payer: United Healthcare All Payer |
$1,629.14
|
|
