|
R3 20DEG XLPE ACET LNR 32*60M
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEG XLPE ACET LNR 32*62M
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEG XLPE ACET LNR 32*62M
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEG XLPE ACET LNR 36*52M
|
Facility
|
IP
|
$8,612.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,119.63 |
| Max. Negotiated Rate |
$8,268.02 |
| Rate for Payer: Aetna Commercial |
$6,631.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,717.77
|
| Rate for Payer: Cash Price |
$4,306.26
|
| Rate for Payer: Cigna Commercial |
$7,148.39
|
| Rate for Payer: First Health Commercial |
$8,181.89
|
| Rate for Payer: Humana Commercial |
$7,320.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,062.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,356.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,579.02
|
| Rate for Payer: Ohio Health Group HMO |
$6,459.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,722.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,119.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,669.88
|
| Rate for Payer: PHCS Commercial |
$8,268.02
|
| Rate for Payer: United Healthcare All Payer |
$7,579.02
|
|
|
R3 20DEG XLPE ACET LNR 36*52M
|
Facility
|
OP
|
$8,612.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,119.63 |
| Max. Negotiated Rate |
$8,268.02 |
| Rate for Payer: Aetna Commercial |
$6,631.64
|
| Rate for Payer: Anthem Medicaid |
$2,961.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,717.77
|
| Rate for Payer: Cash Price |
$4,306.26
|
| Rate for Payer: Cigna Commercial |
$7,148.39
|
| Rate for Payer: First Health Commercial |
$8,181.89
|
| Rate for Payer: Humana Commercial |
$7,320.64
|
| Rate for Payer: Humana KY Medicaid |
$2,961.85
|
| Rate for Payer: Kentucky WC Medicaid |
$2,991.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,062.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,356.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,021.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,579.02
|
| Rate for Payer: Ohio Health Group HMO |
$6,459.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,722.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,119.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,669.88
|
| Rate for Payer: PHCS Commercial |
$8,268.02
|
| Rate for Payer: United Healthcare All Payer |
$7,579.02
|
|
|
R3 20DEG XLPE ACET LNR 36*54M
|
Facility
|
OP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem Medicaid |
$3,307.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Humana KY Medicaid |
$3,307.01
|
| Rate for Payer: Kentucky WC Medicaid |
$3,340.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,373.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*54M
|
Facility
|
IP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*58M
|
Facility
|
IP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*58M
|
Facility
|
OP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem Medicaid |
$3,307.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Humana KY Medicaid |
$3,307.01
|
| Rate for Payer: Kentucky WC Medicaid |
$3,340.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,373.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*60M
|
Facility
|
IP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*60M
|
Facility
|
OP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem Medicaid |
$3,307.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Humana KY Medicaid |
$3,307.01
|
| Rate for Payer: Kentucky WC Medicaid |
$3,340.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,373.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*62M
|
Facility
|
OP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem Medicaid |
$3,307.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Humana KY Medicaid |
$3,307.01
|
| Rate for Payer: Kentucky WC Medicaid |
$3,340.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,373.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*62M
|
Facility
|
IP
|
$9,616.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,250.10 |
| Max. Negotiated Rate |
$9,231.54 |
| Rate for Payer: Aetna Commercial |
$7,404.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,500.63
|
| Rate for Payer: Cash Price |
$4,808.10
|
| Rate for Payer: Cigna Commercial |
$7,981.44
|
| Rate for Payer: First Health Commercial |
$9,135.38
|
| Rate for Payer: Humana Commercial |
$8,173.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,885.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,096.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,884.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,462.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,212.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,923.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,250.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,981.02
|
| Rate for Payer: PHCS Commercial |
$9,231.54
|
| Rate for Payer: United Healthcare All Payer |
$8,462.25
|
|
|
R3 20DEG XLPE ACET LNR 36*64M
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEG XLPE ACET LNR 36*64M
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEGXLPE ACT LNR 36*66/68M
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEGXLPE ACT LNR 36*66/68M
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*46
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*46
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*48
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*48
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20^ XLPE ACET LINER 32*48
|
Facility
|
IP
|
$17,034.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.42 |
| Max. Negotiated Rate |
$16,352.64 |
| Rate for Payer: Aetna Commercial |
$13,116.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,286.52
|
| Rate for Payer: Cash Price |
$8,517.00
|
| Rate for Payer: Cigna Commercial |
$14,138.22
|
| Rate for Payer: First Health Commercial |
$16,182.30
|
| Rate for Payer: Humana Commercial |
$14,478.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,967.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,571.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,110.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,989.92
|
| Rate for Payer: Ohio Health Group HMO |
$12,775.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,406.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,214.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,280.54
|
| Rate for Payer: PHCS Commercial |
$16,352.64
|
| Rate for Payer: United Healthcare All Payer |
$14,989.92
|
|
|
R3 20^ XLPE ACET LINER 32*48
|
Facility
|
OP
|
$17,034.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.42 |
| Max. Negotiated Rate |
$16,352.64 |
| Rate for Payer: Aetna Commercial |
$13,116.18
|
| Rate for Payer: Anthem Medicaid |
$5,857.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,286.52
|
| Rate for Payer: Cash Price |
$8,517.00
|
| Rate for Payer: Cigna Commercial |
$14,138.22
|
| Rate for Payer: First Health Commercial |
$16,182.30
|
| Rate for Payer: Humana Commercial |
$14,478.90
|
| Rate for Payer: Humana KY Medicaid |
$5,857.99
|
| Rate for Payer: Kentucky WC Medicaid |
$5,917.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,967.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,571.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,110.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,975.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,989.92
|
| Rate for Payer: Ohio Health Group HMO |
$12,775.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,406.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,214.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,280.54
|
| Rate for Payer: PHCS Commercial |
$16,352.64
|
| Rate for Payer: United Healthcare All Payer |
$14,989.92
|
|
|
R3 3H HA CTD ACET SHELL 40MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 40MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
