|
SROM 11/13 48MM SPEC +0
|
Facility
|
IP
|
$9,050.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,176.53 |
| Max. Negotiated Rate |
$8,688.25 |
| Rate for Payer: Aetna Commercial |
$6,968.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,059.20
|
| Rate for Payer: Cash Price |
$4,525.13
|
| Rate for Payer: Cigna Commercial |
$7,511.72
|
| Rate for Payer: First Health Commercial |
$8,597.75
|
| Rate for Payer: Humana Commercial |
$7,692.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,421.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,679.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,715.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,964.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,787.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,810.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,176.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,805.58
|
| Rate for Payer: PHCS Commercial |
$8,688.25
|
| Rate for Payer: United Healthcare All Payer |
$7,964.23
|
|
|
SROM 11/13 48MM SPEC +0
|
Facility
|
OP
|
$9,050.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,176.53 |
| Max. Negotiated Rate |
$8,688.25 |
| Rate for Payer: Aetna Commercial |
$6,968.70
|
| Rate for Payer: Anthem Medicaid |
$3,112.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,059.20
|
| Rate for Payer: Cash Price |
$4,525.13
|
| Rate for Payer: Cigna Commercial |
$7,511.72
|
| Rate for Payer: First Health Commercial |
$8,597.75
|
| Rate for Payer: Humana Commercial |
$7,692.72
|
| Rate for Payer: Humana KY Medicaid |
$3,112.38
|
| Rate for Payer: Kentucky WC Medicaid |
$3,144.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,421.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,679.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,715.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,174.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,964.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,787.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,810.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,176.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,805.58
|
| Rate for Payer: PHCS Commercial |
$8,688.25
|
| Rate for Payer: United Healthcare All Payer |
$7,964.23
|
|
|
SROM 11/13 48MM SPEC +3
|
Facility
|
IP
|
$11,804.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,534.58 |
| Max. Negotiated Rate |
$11,332.32 |
| Rate for Payer: Aetna Commercial |
$9,089.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,207.51
|
| Rate for Payer: Cash Price |
$5,902.25
|
| Rate for Payer: Cigna Commercial |
$9,797.74
|
| Rate for Payer: First Health Commercial |
$11,214.28
|
| Rate for Payer: Humana Commercial |
$10,033.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,679.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,711.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,541.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,387.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,853.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,360.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,534.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,659.40
|
| Rate for Payer: PHCS Commercial |
$11,332.32
|
| Rate for Payer: United Healthcare All Payer |
$10,387.96
|
|
|
SROM 11/13 48MM SPEC +3
|
Facility
|
OP
|
$11,804.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,534.58 |
| Max. Negotiated Rate |
$11,332.32 |
| Rate for Payer: Aetna Commercial |
$9,089.46
|
| Rate for Payer: Anthem Medicaid |
$4,059.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,207.51
|
| Rate for Payer: Cash Price |
$5,902.25
|
| Rate for Payer: Cigna Commercial |
$9,797.74
|
| Rate for Payer: First Health Commercial |
$11,214.28
|
| Rate for Payer: Humana Commercial |
$10,033.82
|
| Rate for Payer: Humana KY Medicaid |
$4,059.57
|
| Rate for Payer: Kentucky WC Medicaid |
$4,100.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,679.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,711.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,541.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,141.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,387.96
|
| Rate for Payer: Ohio Health Group HMO |
$8,853.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,360.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,534.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,659.40
|
| Rate for Payer: PHCS Commercial |
$11,332.32
|
| Rate for Payer: United Healthcare All Payer |
$10,387.96
|
|
|
SROM 28MM METAL HEAD 136516500
|
Facility
|
IP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
SROM 28MM METAL HEAD 136516500
|
Facility
|
OP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem Medicaid |
$2,544.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Humana KY Medicaid |
$2,544.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,570.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,595.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
SROM 28MM METAL HEAD 136517500
|
Facility
|
IP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
SROM 28MM METAL HEAD 136517500
|
Facility
|
OP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem Medicaid |
$2,544.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Humana KY Medicaid |
$2,544.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,570.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,595.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
SROM 28MM METAL HEAD 136518500
|
Facility
|
OP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem Medicaid |
$2,544.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Humana KY Medicaid |
$2,544.52
|
| Rate for Payer: Kentucky WC Medicaid |
$2,570.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,595.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
SROM 28MM METAL HEAD 136518500
|
Facility
|
IP
|
$7,399.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$961.87 |
| Max. Negotiated Rate |
$7,103.04 |
| Rate for Payer: Aetna Commercial |
$5,697.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,771.22
|
| Rate for Payer: Cash Price |
$3,699.50
|
| Rate for Payer: Cigna Commercial |
$6,141.17
|
| Rate for Payer: First Health Commercial |
$7,029.05
|
| Rate for Payer: Humana Commercial |
$6,289.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,067.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,460.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,219.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,511.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,549.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,479.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$961.87
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,293.69
|
| Rate for Payer: PHCS Commercial |
$7,103.04
|
| Rate for Payer: United Healthcare All Payer |
$6,511.12
|
|
|
SROM BASE TIB MOD UNTXT LG
|
Facility
|
IP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT LG
|
Facility
|
OP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem Medicaid |
$4,378.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Humana KY Medicaid |
$4,378.75
|
| Rate for Payer: Kentucky WC Medicaid |
$4,423.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,466.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT MED
|
Facility
|
OP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem Medicaid |
$4,378.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Humana KY Medicaid |
$4,378.75
|
| Rate for Payer: Kentucky WC Medicaid |
$4,423.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,466.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT MED
|
Facility
|
IP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT SM
|
Facility
|
IP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT SM
|
Facility
|
OP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem Medicaid |
$4,378.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Humana KY Medicaid |
$4,378.75
|
| Rate for Payer: Kentucky WC Medicaid |
$4,423.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,466.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT XLRG
|
Facility
|
OP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem Medicaid |
$4,378.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Humana KY Medicaid |
$4,378.75
|
| Rate for Payer: Kentucky WC Medicaid |
$4,423.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,466.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT XLRG
|
Facility
|
IP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT XSM
|
Facility
|
OP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem Medicaid |
$4,378.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Humana KY Medicaid |
$4,378.75
|
| Rate for Payer: Kentucky WC Medicaid |
$4,423.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,466.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BASE TIB MOD UNTXT XSM
|
Facility
|
IP
|
$12,732.62
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,655.24 |
| Max. Negotiated Rate |
$12,223.32 |
| Rate for Payer: Aetna Commercial |
$9,804.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,931.44
|
| Rate for Payer: Cash Price |
$6,366.31
|
| Rate for Payer: Cigna Commercial |
$10,568.07
|
| Rate for Payer: First Health Commercial |
$12,095.99
|
| Rate for Payer: Humana Commercial |
$10,822.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,440.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,396.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,819.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,204.71
|
| Rate for Payer: Ohio Health Group HMO |
$9,549.46
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,546.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,655.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,947.11
|
| Rate for Payer: PHCS Commercial |
$12,223.32
|
| Rate for Payer: United Healthcare All Payer |
$11,204.71
|
|
|
SROM BUMPER NOILES MOD MED
|
Facility
|
OP
|
$1,703.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.51 |
| Max. Negotiated Rate |
$1,635.76 |
| Rate for Payer: Aetna Commercial |
$1,312.02
|
| Rate for Payer: Anthem Medicaid |
$585.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,329.06
|
| Rate for Payer: Cash Price |
$851.96
|
| Rate for Payer: Cigna Commercial |
$1,414.25
|
| Rate for Payer: First Health Commercial |
$1,618.72
|
| Rate for Payer: Humana Commercial |
$1,448.33
|
| Rate for Payer: Humana KY Medicaid |
$585.98
|
| Rate for Payer: Kentucky WC Medicaid |
$591.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,397.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,257.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$511.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$597.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,499.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,277.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$528.22
|
| Rate for Payer: PHCS Commercial |
$1,635.76
|
| Rate for Payer: United Healthcare All Payer |
$1,499.45
|
|
|
SROM BUMPER NOILES MOD MED
|
Facility
|
IP
|
$1,703.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.51 |
| Max. Negotiated Rate |
$1,635.76 |
| Rate for Payer: Aetna Commercial |
$1,312.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,329.06
|
| Rate for Payer: Cash Price |
$851.96
|
| Rate for Payer: Cigna Commercial |
$1,414.25
|
| Rate for Payer: First Health Commercial |
$1,618.72
|
| Rate for Payer: Humana Commercial |
$1,448.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,397.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,257.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$511.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,499.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,277.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$528.22
|
| Rate for Payer: PHCS Commercial |
$1,635.76
|
| Rate for Payer: United Healthcare All Payer |
$1,499.45
|
|
|
SROM BUMPER NOILES MOD SML
|
Facility
|
OP
|
$1,703.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.51 |
| Max. Negotiated Rate |
$1,635.76 |
| Rate for Payer: Aetna Commercial |
$1,312.02
|
| Rate for Payer: Anthem Medicaid |
$585.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,329.06
|
| Rate for Payer: Cash Price |
$851.96
|
| Rate for Payer: Cigna Commercial |
$1,414.25
|
| Rate for Payer: First Health Commercial |
$1,618.72
|
| Rate for Payer: Humana Commercial |
$1,448.33
|
| Rate for Payer: Humana KY Medicaid |
$585.98
|
| Rate for Payer: Kentucky WC Medicaid |
$591.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,397.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,257.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$511.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$597.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,499.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,277.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$528.22
|
| Rate for Payer: PHCS Commercial |
$1,635.76
|
| Rate for Payer: United Healthcare All Payer |
$1,499.45
|
|
|
SROM BUMPER NOILES MOD SML
|
Facility
|
IP
|
$1,703.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$221.51 |
| Max. Negotiated Rate |
$1,635.76 |
| Rate for Payer: Aetna Commercial |
$1,312.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,329.06
|
| Rate for Payer: Cash Price |
$851.96
|
| Rate for Payer: Cigna Commercial |
$1,414.25
|
| Rate for Payer: First Health Commercial |
$1,618.72
|
| Rate for Payer: Humana Commercial |
$1,448.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,397.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,257.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$511.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,499.45
|
| Rate for Payer: Ohio Health Group HMO |
$1,277.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$221.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$528.22
|
| Rate for Payer: PHCS Commercial |
$1,635.76
|
| Rate for Payer: United Healthcare All Payer |
$1,499.45
|
|
|
SROM EXT FEM STM BOW 11*150
|
Facility
|
IP
|
$7,290.74
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$947.80 |
| Max. Negotiated Rate |
$6,999.11 |
| Rate for Payer: Aetna Commercial |
$5,613.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,686.78
|
| Rate for Payer: Cash Price |
$3,645.37
|
| Rate for Payer: Cigna Commercial |
$6,051.31
|
| Rate for Payer: First Health Commercial |
$6,926.20
|
| Rate for Payer: Humana Commercial |
$6,197.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,978.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,380.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,187.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,415.85
|
| Rate for Payer: Ohio Health Group HMO |
$5,468.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,458.15
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$947.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,260.13
|
| Rate for Payer: PHCS Commercial |
$6,999.11
|
| Rate for Payer: United Healthcare All Payer |
$6,415.85
|
|
