|
SHELL STIKTITETHRDD FSO 9 62MM
|
Facility
|
OP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem Medicaid |
$4,316.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Humana KY Medicaid |
$4,316.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,360.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,403.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL STIKTITETHRDD FSO 9 64MM
|
Facility
|
OP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem Medicaid |
$4,316.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Humana KY Medicaid |
$4,316.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,360.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,403.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL STIKTITETHRDD FSO 9 64MM
|
Facility
|
IP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL STIKTITETHRDD FSO 9 66MM
|
Facility
|
OP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem Medicaid |
$4,316.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Humana KY Medicaid |
$4,316.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,360.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,403.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL STIKTITETHRDD FSO 9 66MM
|
Facility
|
IP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL STIKTITETHRDD FSO 9 68MM
|
Facility
|
OP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem Medicaid |
$4,316.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Humana KY Medicaid |
$4,316.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,360.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,403.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL STIKTITETHRDD FSO 9 68MM
|
Facility
|
IP
|
$12,552.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,631.86 |
| Max. Negotiated Rate |
$12,050.64 |
| Rate for Payer: Aetna Commercial |
$9,665.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,791.14
|
| Rate for Payer: Cash Price |
$6,276.38
|
| Rate for Payer: Cigna Commercial |
$10,418.78
|
| Rate for Payer: First Health Commercial |
$11,925.11
|
| Rate for Payer: Humana Commercial |
$10,669.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,293.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,263.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,765.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,046.42
|
| Rate for Payer: Ohio Health Group HMO |
$9,414.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,510.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,631.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,891.35
|
| Rate for Payer: PHCS Commercial |
$12,050.64
|
| Rate for Payer: United Healthcare All Payer |
$11,046.42
|
|
|
SHELL TI-PLASMA/HA NON-CEM 43
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 43
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 45
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 45
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 47
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 47
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 49
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 49
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 51
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 51
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 53
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 53
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 55
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 55
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 57
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 57
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 59
|
Facility
|
OP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem Medicaid |
$5,714.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Humana KY Medicaid |
$5,714.07
|
| Rate for Payer: Kentucky WC Medicaid |
$5,772.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,828.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
|
SHELL TI-PLASMA/HA NON-CEM 59
|
Facility
|
IP
|
$16,615.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.02 |
| Max. Negotiated Rate |
$15,950.88 |
| Rate for Payer: Aetna Commercial |
$12,793.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,960.09
|
| Rate for Payer: Cash Price |
$8,307.75
|
| Rate for Payer: Cigna Commercial |
$13,790.86
|
| Rate for Payer: First Health Commercial |
$15,784.72
|
| Rate for Payer: Humana Commercial |
$14,123.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,624.71
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,262.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,984.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,621.64
|
| Rate for Payer: Ohio Health Group HMO |
$12,461.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,323.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,150.80
|
| Rate for Payer: PHCS Commercial |
$15,950.88
|
| Rate for Payer: United Healthcare All Payer |
$14,621.64
|
|
