|
R3 0 XLPE ACET LINER 36*52
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*54
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*54
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*56
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*56
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*58
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*58
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*60
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*60
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*62
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*62
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*64
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*64
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*66/68
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 0 XLPE ACET LINER 36*66/68
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEG 32ID DISP TRLLNR 48OD
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 48OD
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 50OD
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 50OD
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 52OD
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 52OD
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 54OD
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 54OD
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 56OD
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
R3 20DEG 32ID DISP TRLLNR 56OD
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
