|
SIZER STYLE 20 RE-STERIL 140CC
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 160CC
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 160CC
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 180CC
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 180CC
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 200CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 20 RE-STERIL 200CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 20 RE-STERIL 300CC
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 300CC
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 20 RE-STERIL 550CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 20 RE-STERIL 550CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 20 RE-STERIL 600CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 20 RE-STERIL 600CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 120CC
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 45 RE-STERIL 120CC
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 45 RE-STERIL 160CC
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SIZER STYLE 45 RE-STERIL 160CC
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
SIZER STYLE 45 RE-STERIL 200CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 200CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 240CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 240CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 280CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 280CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE 45 RE-STERIL 320CC
|
Facility
|
IP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
|
SIZER STYLE 45 RE-STERIL 320CC
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$561.00 |
| Max. Negotiated Rate |
$1,795.20 |
| Rate for Payer: Aetna Commercial |
$1,439.90
|
| Rate for Payer: Anthem Medicaid |
$643.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.60
|
| Rate for Payer: Cash Price |
$935.00
|
| Rate for Payer: Cigna Commercial |
$1,552.10
|
| Rate for Payer: First Health Commercial |
$1,776.50
|
| Rate for Payer: Humana Commercial |
$1,589.50
|
| Rate for Payer: Humana KY Medicaid |
$643.09
|
| Rate for Payer: Kentucky WC Medicaid |
$649.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,533.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,380.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$561.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$656.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,496.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,626.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,290.30
|
| Rate for Payer: PHCS Commercial |
$1,795.20
|
| Rate for Payer: United Healthcare All Payer |
$1,645.60
|
|
