|
STEM LAT TI/HA NON-CEM 3
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 4
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 4
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 5
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 5
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 6
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 6
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 7
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 7
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 8
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 8
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 9
|
Facility
|
OP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem Medicaid |
$3,980.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Humana KY Medicaid |
$3,980.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,020.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,060.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LAT TI/HA NON-CEM 9
|
Facility
|
IP
|
$11,574.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,472.20 |
| Max. Negotiated Rate |
$11,111.04 |
| Rate for Payer: Aetna Commercial |
$8,911.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,027.72
|
| Rate for Payer: Cash Price |
$5,787.00
|
| Rate for Payer: Cigna Commercial |
$9,606.42
|
| Rate for Payer: First Health Commercial |
$10,995.30
|
| Rate for Payer: Humana Commercial |
$9,837.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,490.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,541.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,472.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,185.12
|
| Rate for Payer: Ohio Health Group HMO |
$8,680.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,259.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,069.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,986.06
|
| Rate for Payer: PHCS Commercial |
$11,111.04
|
| Rate for Payer: United Healthcare All Payer |
$10,185.12
|
|
|
STEM LEGION PF SP 10MMX160MM
|
Facility
|
OP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem Medicaid |
$3,536.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Humana KY Medicaid |
$3,536.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3,572.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,607.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 10MMX160MM
|
Facility
|
IP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 11MMX160MM
|
Facility
|
IP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 11MMX160MM
|
Facility
|
OP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem Medicaid |
$3,536.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Humana KY Medicaid |
$3,536.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3,572.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,607.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 12MMX160MM
|
Facility
|
IP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 12MMX160MM
|
Facility
|
OP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem Medicaid |
$3,536.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Humana KY Medicaid |
$3,536.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3,572.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,607.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 13MMX160MM
|
Facility
|
OP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem Medicaid |
$3,536.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Humana KY Medicaid |
$3,536.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3,572.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,607.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 13MMX160MM
|
Facility
|
IP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 14MMX160MM
|
Facility
|
OP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem Medicaid |
$3,536.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Humana KY Medicaid |
$3,536.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3,572.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,607.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 14MMX160MM
|
Facility
|
IP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 15MMX160MM
|
Facility
|
IP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
|
STEM LEGION PF SP 15MMX160MM
|
Facility
|
OP
|
$10,283.58
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,085.07 |
| Max. Negotiated Rate |
$9,872.24 |
| Rate for Payer: Aetna Commercial |
$7,918.36
|
| Rate for Payer: Anthem Medicaid |
$3,536.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,021.19
|
| Rate for Payer: Cash Price |
$5,141.79
|
| Rate for Payer: Cigna Commercial |
$8,535.37
|
| Rate for Payer: First Health Commercial |
$9,769.40
|
| Rate for Payer: Humana Commercial |
$8,741.04
|
| Rate for Payer: Humana KY Medicaid |
$3,536.52
|
| Rate for Payer: Kentucky WC Medicaid |
$3,572.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,432.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,589.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,085.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,607.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,049.55
|
| Rate for Payer: Ohio Health Group HMO |
$7,712.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,226.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,946.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,095.67
|
| Rate for Payer: PHCS Commercial |
$9,872.24
|
| Rate for Payer: United Healthcare All Payer |
$9,049.55
|
|
