|
REF INR 28ID 62-64OD ANT+4 SZH
|
Facility
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 62-64OD ANT+4 SZH
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 66-68OD ANT+4 SZJ
|
Facility
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 66-68OD ANT+4 SZJ
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 70-76OD ANT+4 SZK
|
Facility
|
OP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem Medicaid |
$1,687.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Humana KY Medicaid |
$1,687.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,704.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,721.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INR 28ID 70-76OD ANT+4 SZK
|
Facility
|
IP
|
$4,907.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,472.10 |
| Max. Negotiated Rate |
$4,710.72 |
| Rate for Payer: Aetna Commercial |
$3,778.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,827.46
|
| Rate for Payer: Cash Price |
$2,453.50
|
| Rate for Payer: Cigna Commercial |
$4,072.81
|
| Rate for Payer: First Health Commercial |
$4,661.65
|
| Rate for Payer: Humana Commercial |
$4,170.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,023.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,621.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,472.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,318.16
|
| Rate for Payer: Ohio Health Group HMO |
$3,680.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,925.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,269.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,385.83
|
| Rate for Payer: PHCS Commercial |
$4,710.72
|
| Rate for Payer: United Healthcare All Payer |
$4,318.16
|
|
|
REF INTERFIT THRD HOLE COVER
|
Facility
|
IP
|
$1,553.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.09 |
| Max. Negotiated Rate |
$1,491.48 |
| Rate for Payer: Aetna Commercial |
$1,196.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,211.83
|
| Rate for Payer: Cash Price |
$776.81
|
| Rate for Payer: Cigna Commercial |
$1,289.51
|
| Rate for Payer: First Health Commercial |
$1,475.95
|
| Rate for Payer: Humana Commercial |
$1,320.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,273.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,146.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$466.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,367.19
|
| Rate for Payer: Ohio Health Group HMO |
$1,165.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,242.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,351.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.00
|
| Rate for Payer: PHCS Commercial |
$1,491.48
|
| Rate for Payer: United Healthcare All Payer |
$1,367.19
|
|
|
REF INTERFIT THRD HOLE COVER
|
Facility
|
OP
|
$1,553.63
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$466.09 |
| Max. Negotiated Rate |
$1,491.48 |
| Rate for Payer: Aetna Commercial |
$1,196.30
|
| Rate for Payer: Anthem Medicaid |
$534.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,211.83
|
| Rate for Payer: Cash Price |
$776.81
|
| Rate for Payer: Cigna Commercial |
$1,289.51
|
| Rate for Payer: First Health Commercial |
$1,475.95
|
| Rate for Payer: Humana Commercial |
$1,320.59
|
| Rate for Payer: Humana KY Medicaid |
$534.29
|
| Rate for Payer: Kentucky WC Medicaid |
$539.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,273.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,146.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$466.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$545.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,367.19
|
| Rate for Payer: Ohio Health Group HMO |
$1,165.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,242.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,351.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,072.00
|
| Rate for Payer: PHCS Commercial |
$1,491.48
|
| Rate for Payer: United Healthcare All Payer |
$1,367.19
|
|
|
REF I POR ACET SHELL 42OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 42OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 44OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 44OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 46OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 46OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 48OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 48OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 50OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 50OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 52OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 52OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 54OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 54OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 56OD
|
Facility
|
OP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem Medicaid |
$4,021.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Humana KY Medicaid |
$4,021.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,062.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,102.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 56OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
|
REF I POR ACET SHELL 58OD
|
Facility
|
IP
|
$11,694.93
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,508.48 |
| Max. Negotiated Rate |
$11,227.13 |
| Rate for Payer: Aetna Commercial |
$9,005.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,122.05
|
| Rate for Payer: Cash Price |
$5,847.46
|
| Rate for Payer: Cigna Commercial |
$9,706.79
|
| Rate for Payer: First Health Commercial |
$11,110.18
|
| Rate for Payer: Humana Commercial |
$9,940.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,589.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,630.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,508.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,291.54
|
| Rate for Payer: Ohio Health Group HMO |
$8,771.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,355.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,174.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,069.50
|
| Rate for Payer: PHCS Commercial |
$11,227.13
|
| Rate for Payer: United Healthcare All Payer |
$10,291.54
|
|
