|
SYN POR PLUS HA SO STEM SZ 10
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 11
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 11
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 12
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 12
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 13
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 13
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 14
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 14
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 15
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 15
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 16
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 16
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 17
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 17
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
SYN POR PLUS HA SO STEM SZ 18
|
Facility
|
IP
|
$18,402.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.26 |
| Max. Negotiated Rate |
$17,665.92 |
| Rate for Payer: Aetna Commercial |
$14,169.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,353.56
|
| Rate for Payer: Cash Price |
$9,201.00
|
| Rate for Payer: Cigna Commercial |
$15,273.66
|
| Rate for Payer: First Health Commercial |
$17,481.90
|
| Rate for Payer: Humana Commercial |
$15,641.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,089.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,580.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,520.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,193.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,801.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,680.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,392.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,704.62
|
| Rate for Payer: PHCS Commercial |
$17,665.92
|
| Rate for Payer: United Healthcare All Payer |
$16,193.76
|
|
|
SYN POR PLUS HA SO STEM SZ 18
|
Facility
|
OP
|
$18,402.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.26 |
| Max. Negotiated Rate |
$17,665.92 |
| Rate for Payer: Aetna Commercial |
$14,169.54
|
| Rate for Payer: Anthem Medicaid |
$6,328.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,353.56
|
| Rate for Payer: Cash Price |
$9,201.00
|
| Rate for Payer: Cigna Commercial |
$15,273.66
|
| Rate for Payer: First Health Commercial |
$17,481.90
|
| Rate for Payer: Humana Commercial |
$15,641.70
|
| Rate for Payer: Humana KY Medicaid |
$6,328.45
|
| Rate for Payer: Kentucky WC Medicaid |
$6,392.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,089.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,580.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,520.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,455.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,193.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,801.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,680.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,392.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,704.62
|
| Rate for Payer: PHCS Commercial |
$17,665.92
|
| Rate for Payer: United Healthcare All Payer |
$16,193.76
|
|
|
SYN POR PLUS HA SO STEM SZ 8
|
Facility
|
IP
|
$20,025.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,603.28 |
| Max. Negotiated Rate |
$19,224.23 |
| Rate for Payer: Aetna Commercial |
$15,419.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,619.69
|
| Rate for Payer: Cash Price |
$10,012.62
|
| Rate for Payer: Cigna Commercial |
$16,620.95
|
| Rate for Payer: First Health Commercial |
$19,023.98
|
| Rate for Payer: Humana Commercial |
$17,021.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,420.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,778.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,007.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,622.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,018.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,005.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,603.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,207.82
|
| Rate for Payer: PHCS Commercial |
$19,224.23
|
| Rate for Payer: United Healthcare All Payer |
$17,622.21
|
|
|
SYN POR PLUS HA SO STEM SZ 8
|
Facility
|
OP
|
$20,025.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,603.28 |
| Max. Negotiated Rate |
$19,224.23 |
| Rate for Payer: Aetna Commercial |
$15,419.43
|
| Rate for Payer: Anthem Medicaid |
$6,886.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,619.69
|
| Rate for Payer: Cash Price |
$10,012.62
|
| Rate for Payer: Cigna Commercial |
$16,620.95
|
| Rate for Payer: First Health Commercial |
$19,023.98
|
| Rate for Payer: Humana Commercial |
$17,021.45
|
| Rate for Payer: Humana KY Medicaid |
$6,886.68
|
| Rate for Payer: Kentucky WC Medicaid |
$6,956.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,420.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,778.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,007.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,024.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,622.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,018.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,005.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,603.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,207.82
|
| Rate for Payer: PHCS Commercial |
$19,224.23
|
| Rate for Payer: United Healthcare All Payer |
$17,622.21
|
|
|
SYN POR PLUS HA SO STEM SZ 9
|
Facility
|
IP
|
$20,025.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,603.28 |
| Max. Negotiated Rate |
$19,224.23 |
| Rate for Payer: Aetna Commercial |
$15,419.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,619.69
|
| Rate for Payer: Cash Price |
$10,012.62
|
| Rate for Payer: Cigna Commercial |
$16,620.95
|
| Rate for Payer: First Health Commercial |
$19,023.98
|
| Rate for Payer: Humana Commercial |
$17,021.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,420.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,778.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,007.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,622.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,018.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,005.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,603.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,207.82
|
| Rate for Payer: PHCS Commercial |
$19,224.23
|
| Rate for Payer: United Healthcare All Payer |
$17,622.21
|
|
|
SYN POR PLUS HA SO STEM SZ 9
|
Facility
|
OP
|
$20,025.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,603.28 |
| Max. Negotiated Rate |
$19,224.23 |
| Rate for Payer: Aetna Commercial |
$15,419.43
|
| Rate for Payer: Anthem Medicaid |
$6,886.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,619.69
|
| Rate for Payer: Cash Price |
$10,012.62
|
| Rate for Payer: Cigna Commercial |
$16,620.95
|
| Rate for Payer: First Health Commercial |
$19,023.98
|
| Rate for Payer: Humana Commercial |
$17,021.45
|
| Rate for Payer: Humana KY Medicaid |
$6,886.68
|
| Rate for Payer: Kentucky WC Medicaid |
$6,956.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,420.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,778.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,007.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,024.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,622.21
|
| Rate for Payer: Ohio Health Group HMO |
$15,018.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,005.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,603.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,207.82
|
| Rate for Payer: PHCS Commercial |
$19,224.23
|
| Rate for Payer: United Healthcare All Payer |
$17,622.21
|
|
|
SYNTHROID 0.025MG TAB
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
25001475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
SYNTHROID 0.025MG TAB
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
25001475
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
SYNTHROID 10mcg(GEN) SDV
|
Facility
|
OP
|
$533.58
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
25003508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$512.24 |
| Rate for Payer: Aetna Commercial |
$410.86
|
| Rate for Payer: Anthem Medicaid |
$183.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.19
|
| Rate for Payer: Cash Price |
$266.79
|
| Rate for Payer: Cigna Commercial |
$442.87
|
| Rate for Payer: First Health Commercial |
$506.90
|
| Rate for Payer: Humana Commercial |
$453.54
|
| Rate for Payer: Humana KY Medicaid |
$183.50
|
| Rate for Payer: Kentucky WC Medicaid |
$185.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$187.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.55
|
| Rate for Payer: Ohio Health Group HMO |
$400.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.41
|
| Rate for Payer: PHCS Commercial |
$512.24
|
| Rate for Payer: United Healthcare All Payer |
$469.55
|
|
|
SYNTHROID 10mcg(GEN) SDV
|
Facility
|
IP
|
$533.58
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
25003508
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$69.37 |
| Max. Negotiated Rate |
$512.24 |
| Rate for Payer: Aetna Commercial |
$410.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$416.19
|
| Rate for Payer: Cash Price |
$266.79
|
| Rate for Payer: Cigna Commercial |
$442.87
|
| Rate for Payer: First Health Commercial |
$506.90
|
| Rate for Payer: Humana Commercial |
$453.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$437.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$393.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$160.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$469.55
|
| Rate for Payer: Ohio Health Group HMO |
$400.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$106.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$69.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$165.41
|
| Rate for Payer: PHCS Commercial |
$512.24
|
| Rate for Payer: United Healthcare All Payer |
$469.55
|
|
