|
SHELL TRID2 TRIT SLDBACK 52E
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 52E
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 54E
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 54E
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 56F
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 56F
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 58F
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 58F
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 60G
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 60G
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 62G
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 62G
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 64H
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 64H
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 66H
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRID2 TRIT SLDBACK 66H
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
SHELL TRILOGY ACET SOLID 40MM
|
Facility
|
OP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem Medicaid |
$2,632.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Humana KY Medicaid |
$2,632.38
|
| Rate for Payer: Kentucky WC Medicaid |
$2,659.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,685.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 40MM
|
Facility
|
IP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 42MM
|
Facility
|
OP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem Medicaid |
$2,632.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Humana KY Medicaid |
$2,632.38
|
| Rate for Payer: Kentucky WC Medicaid |
$2,659.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,685.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 42MM
|
Facility
|
IP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 44MM
|
Facility
|
OP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem Medicaid |
$2,632.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Humana KY Medicaid |
$2,632.38
|
| Rate for Payer: Kentucky WC Medicaid |
$2,659.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,685.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 44MM
|
Facility
|
IP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 46MM
|
Facility
|
OP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem Medicaid |
$2,632.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Humana KY Medicaid |
$2,632.38
|
| Rate for Payer: Kentucky WC Medicaid |
$2,659.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,685.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 46MM
|
Facility
|
IP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
|
SHELL TRILOGY ACET SOLID 48MM
|
Facility
|
OP
|
$7,654.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$995.08 |
| Max. Negotiated Rate |
$7,348.32 |
| Rate for Payer: Aetna Commercial |
$5,893.96
|
| Rate for Payer: Anthem Medicaid |
$2,632.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,970.51
|
| Rate for Payer: Cash Price |
$3,827.25
|
| Rate for Payer: Cigna Commercial |
$6,353.24
|
| Rate for Payer: First Health Commercial |
$7,271.78
|
| Rate for Payer: Humana Commercial |
$6,506.32
|
| Rate for Payer: Humana KY Medicaid |
$2,632.38
|
| Rate for Payer: Kentucky WC Medicaid |
$2,659.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,276.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,649.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,296.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,685.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,735.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,740.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,530.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$995.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,372.90
|
| Rate for Payer: PHCS Commercial |
$7,348.32
|
| Rate for Payer: United Healthcare All Payer |
$6,735.96
|
|
