|
SROM 11/13 44MM SPEC +9
|
Facility
|
OP
|
$12,381.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,714.42 |
| Max. Negotiated Rate |
$11,886.14 |
| Rate for Payer: Aetna Commercial |
$9,533.68
|
| Rate for Payer: Anthem Medicaid |
$4,257.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,657.49
|
| Rate for Payer: Cash Price |
$6,190.70
|
| Rate for Payer: Cigna Commercial |
$10,276.56
|
| Rate for Payer: First Health Commercial |
$11,762.33
|
| Rate for Payer: Humana Commercial |
$10,524.19
|
| Rate for Payer: Humana KY Medicaid |
$4,257.96
|
| Rate for Payer: Kentucky WC Medicaid |
$4,301.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,152.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,137.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,714.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,343.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,895.63
|
| Rate for Payer: Ohio Health Group HMO |
$9,286.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,905.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,771.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,543.17
|
| Rate for Payer: PHCS Commercial |
$11,886.14
|
| Rate for Payer: United Healthcare All Payer |
$10,895.63
|
|
|
SROM 11/13 48MM SPEC +0
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
SROM 11/13 48MM SPEC +0
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
SROM 11/13 48MM SPEC +3
|
Facility
|
IP
|
$12,051.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,615.33 |
| Max. Negotiated Rate |
$11,569.06 |
| Rate for Payer: Aetna Commercial |
$9,279.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,399.86
|
| Rate for Payer: Cash Price |
$6,025.55
|
| Rate for Payer: Cigna Commercial |
$10,002.41
|
| Rate for Payer: First Health Commercial |
$11,448.55
|
| Rate for Payer: Humana Commercial |
$10,243.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,881.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,893.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,615.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,604.97
|
| Rate for Payer: Ohio Health Group HMO |
$9,038.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,640.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,484.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,315.26
|
| Rate for Payer: PHCS Commercial |
$11,569.06
|
| Rate for Payer: United Healthcare All Payer |
$10,604.97
|
|
|
SROM 11/13 48MM SPEC +3
|
Facility
|
OP
|
$12,051.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,615.33 |
| Max. Negotiated Rate |
$11,569.06 |
| Rate for Payer: Aetna Commercial |
$9,279.35
|
| Rate for Payer: Anthem Medicaid |
$4,144.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,399.86
|
| Rate for Payer: Cash Price |
$6,025.55
|
| Rate for Payer: Cigna Commercial |
$10,002.41
|
| Rate for Payer: First Health Commercial |
$11,448.55
|
| Rate for Payer: Humana Commercial |
$10,243.43
|
| Rate for Payer: Humana KY Medicaid |
$4,144.37
|
| Rate for Payer: Kentucky WC Medicaid |
$4,186.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,881.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,893.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,615.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,227.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,604.97
|
| Rate for Payer: Ohio Health Group HMO |
$9,038.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,640.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,484.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,315.26
|
| Rate for Payer: PHCS Commercial |
$11,569.06
|
| Rate for Payer: United Healthcare All Payer |
$10,604.97
|
|
|
SROM 28MM METAL HEAD 136516500
|
Facility
|
IP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
SROM 28MM METAL HEAD 136516500
|
Facility
|
OP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem Medicaid |
$2,613.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Humana KY Medicaid |
$2,613.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,639.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,665.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
SROM 28MM METAL HEAD 136517500
|
Facility
|
OP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem Medicaid |
$2,613.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Humana KY Medicaid |
$2,613.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,639.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,665.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
SROM 28MM METAL HEAD 136517500
|
Facility
|
IP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
SROM 28MM METAL HEAD 136518500
|
Facility
|
IP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
SROM 28MM METAL HEAD 136518500
|
Facility
|
OP
|
$7,599.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,279.70 |
| Max. Negotiated Rate |
$7,295.04 |
| Rate for Payer: Aetna Commercial |
$5,851.23
|
| Rate for Payer: Anthem Medicaid |
$2,613.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,927.22
|
| Rate for Payer: Cash Price |
$3,799.50
|
| Rate for Payer: Cigna Commercial |
$6,307.17
|
| Rate for Payer: First Health Commercial |
$7,219.05
|
| Rate for Payer: Humana Commercial |
$6,459.15
|
| Rate for Payer: Humana KY Medicaid |
$2,613.30
|
| Rate for Payer: Kentucky WC Medicaid |
$2,639.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,231.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,608.06
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,279.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,665.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,687.12
|
| Rate for Payer: Ohio Health Group HMO |
$5,699.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,079.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,611.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,243.31
|
| Rate for Payer: PHCS Commercial |
$7,295.04
|
| Rate for Payer: United Healthcare All Payer |
$6,687.12
|
|
|
SROM BASE TIB MOD UNTXT LG
|
Facility
|
IP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT LG
|
Facility
|
OP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem Medicaid |
$4,465.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Humana KY Medicaid |
$4,465.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,510.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,554.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT MED
|
Facility
|
IP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT MED
|
Facility
|
OP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem Medicaid |
$4,465.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Humana KY Medicaid |
$4,465.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,510.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,554.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT SM
|
Facility
|
OP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem Medicaid |
$4,465.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Humana KY Medicaid |
$4,465.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,510.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,554.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT SM
|
Facility
|
IP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT XLRG
|
Facility
|
IP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT XLRG
|
Facility
|
OP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem Medicaid |
$4,465.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Humana KY Medicaid |
$4,465.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,510.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,554.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT XSM
|
Facility
|
IP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BASE TIB MOD UNTXT XSM
|
Facility
|
OP
|
$12,984.31
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,895.29 |
| Max. Negotiated Rate |
$12,464.94 |
| Rate for Payer: Aetna Commercial |
$9,997.92
|
| Rate for Payer: Anthem Medicaid |
$4,465.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,127.76
|
| Rate for Payer: Cash Price |
$6,492.15
|
| Rate for Payer: Cigna Commercial |
$10,776.98
|
| Rate for Payer: First Health Commercial |
$12,335.09
|
| Rate for Payer: Humana Commercial |
$11,036.66
|
| Rate for Payer: Humana KY Medicaid |
$4,465.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,510.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,647.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,582.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,895.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,554.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,426.19
|
| Rate for Payer: Ohio Health Group HMO |
$9,738.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,387.45
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,296.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,959.17
|
| Rate for Payer: PHCS Commercial |
$12,464.94
|
| Rate for Payer: United Healthcare All Payer |
$11,426.19
|
|
|
SROM BUMPER NOILES MOD MED
|
Facility
|
OP
|
$1,684.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.28 |
| Max. Negotiated Rate |
$1,616.89 |
| Rate for Payer: Aetna Commercial |
$1,296.88
|
| Rate for Payer: Anthem Medicaid |
$579.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,313.72
|
| Rate for Payer: Cash Price |
$842.13
|
| Rate for Payer: Cigna Commercial |
$1,397.94
|
| Rate for Payer: First Health Commercial |
$1,600.05
|
| Rate for Payer: Humana Commercial |
$1,431.62
|
| Rate for Payer: Humana KY Medicaid |
$579.22
|
| Rate for Payer: Kentucky WC Medicaid |
$585.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,242.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$505.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$590.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,347.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,465.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,162.14
|
| Rate for Payer: PHCS Commercial |
$1,616.89
|
| Rate for Payer: United Healthcare All Payer |
$1,482.15
|
|
|
SROM BUMPER NOILES MOD MED
|
Facility
|
IP
|
$1,684.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.28 |
| Max. Negotiated Rate |
$1,616.89 |
| Rate for Payer: Aetna Commercial |
$1,296.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,313.72
|
| Rate for Payer: Cash Price |
$842.13
|
| Rate for Payer: Cigna Commercial |
$1,397.94
|
| Rate for Payer: First Health Commercial |
$1,600.05
|
| Rate for Payer: Humana Commercial |
$1,431.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,242.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$505.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,347.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,465.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,162.14
|
| Rate for Payer: PHCS Commercial |
$1,616.89
|
| Rate for Payer: United Healthcare All Payer |
$1,482.15
|
|
|
SROM BUMPER NOILES MOD SML
|
Facility
|
IP
|
$1,684.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.28 |
| Max. Negotiated Rate |
$1,616.89 |
| Rate for Payer: Aetna Commercial |
$1,296.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,313.72
|
| Rate for Payer: Cash Price |
$842.13
|
| Rate for Payer: Cigna Commercial |
$1,397.94
|
| Rate for Payer: First Health Commercial |
$1,600.05
|
| Rate for Payer: Humana Commercial |
$1,431.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,242.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$505.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,347.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,465.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,162.14
|
| Rate for Payer: PHCS Commercial |
$1,616.89
|
| Rate for Payer: United Healthcare All Payer |
$1,482.15
|
|
|
SROM BUMPER NOILES MOD SML
|
Facility
|
OP
|
$1,684.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.28 |
| Max. Negotiated Rate |
$1,616.89 |
| Rate for Payer: Aetna Commercial |
$1,296.88
|
| Rate for Payer: Anthem Medicaid |
$579.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,313.72
|
| Rate for Payer: Cash Price |
$842.13
|
| Rate for Payer: Cigna Commercial |
$1,397.94
|
| Rate for Payer: First Health Commercial |
$1,600.05
|
| Rate for Payer: Humana Commercial |
$1,431.62
|
| Rate for Payer: Humana KY Medicaid |
$579.22
|
| Rate for Payer: Kentucky WC Medicaid |
$585.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,381.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,242.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$505.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$590.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,482.15
|
| Rate for Payer: Ohio Health Group HMO |
$1,263.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,347.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,465.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,162.14
|
| Rate for Payer: PHCS Commercial |
$1,616.89
|
| Rate for Payer: United Healthcare All Payer |
$1,482.15
|
|
