|
BREAST IMP HIGH PROFILE 140CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 140CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 160CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 160CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 180CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 180CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 200CC
|
Facility
|
OP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem Medicaid |
$1,779.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Humana KY Medicaid |
$1,779.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,797.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,815.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
BREAST IMP HIGH PROFILE 200CC
|
Facility
|
IP
|
$5,175.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$672.75 |
| Max. Negotiated Rate |
$4,968.00 |
| Rate for Payer: Aetna Commercial |
$3,984.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,036.50
|
| Rate for Payer: Cash Price |
$2,587.50
|
| Rate for Payer: Cigna Commercial |
$4,295.25
|
| Rate for Payer: First Health Commercial |
$4,916.25
|
| Rate for Payer: Humana Commercial |
$4,398.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,243.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,819.15
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,552.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,554.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,881.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,035.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$672.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,604.25
|
| Rate for Payer: PHCS Commercial |
$4,968.00
|
| Rate for Payer: United Healthcare All Payer |
$4,554.00
|
|
|
BREAST IMP HIGH PROFILE 230CC
|
Facility
|
OP
|
$5,444.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$707.78 |
| Max. Negotiated Rate |
$5,226.72 |
| Rate for Payer: Aetna Commercial |
$4,192.26
|
| Rate for Payer: Anthem Medicaid |
$1,872.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,246.71
|
| Rate for Payer: Cash Price |
$2,722.25
|
| Rate for Payer: Cigna Commercial |
$4,518.94
|
| Rate for Payer: First Health Commercial |
$5,172.28
|
| Rate for Payer: Humana Commercial |
$4,627.82
|
| Rate for Payer: Humana KY Medicaid |
$1,872.36
|
| Rate for Payer: Kentucky WC Medicaid |
$1,891.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,464.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,018.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,633.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,909.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,791.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,083.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,088.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.80
|
| Rate for Payer: PHCS Commercial |
$5,226.72
|
| Rate for Payer: United Healthcare All Payer |
$4,791.16
|
|
|
BREAST IMP HIGH PROFILE 230CC
|
Facility
|
IP
|
$5,444.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$707.78 |
| Max. Negotiated Rate |
$5,226.72 |
| Rate for Payer: Aetna Commercial |
$4,192.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,246.71
|
| Rate for Payer: Cash Price |
$2,722.25
|
| Rate for Payer: Cigna Commercial |
$4,518.94
|
| Rate for Payer: First Health Commercial |
$5,172.28
|
| Rate for Payer: Humana Commercial |
$4,627.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,464.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,018.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,633.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,791.16
|
| Rate for Payer: Ohio Health Group HMO |
$4,083.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,088.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$707.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,687.80
|
| Rate for Payer: PHCS Commercial |
$5,226.72
|
| Rate for Payer: United Healthcare All Payer |
$4,791.16
|
|
|
BREAST IMP HIGH PROFILE 260CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 260CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 280CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 280CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 300CC
|
Facility
|
IP
|
$5,570.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$5,347.68 |
| Rate for Payer: Aetna Commercial |
$4,289.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,344.99
|
| Rate for Payer: Cash Price |
$2,785.25
|
| Rate for Payer: Cigna Commercial |
$4,623.52
|
| Rate for Payer: First Health Commercial |
$5,291.98
|
| Rate for Payer: Humana Commercial |
$4,734.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,567.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,177.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,114.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,726.86
|
| Rate for Payer: PHCS Commercial |
$5,347.68
|
| Rate for Payer: United Healthcare All Payer |
$4,902.04
|
|
|
BREAST IMP HIGH PROFILE 300CC
|
Facility
|
OP
|
$5,570.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$5,347.68 |
| Rate for Payer: Aetna Commercial |
$4,289.28
|
| Rate for Payer: Anthem Medicaid |
$1,915.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,344.99
|
| Rate for Payer: Cash Price |
$2,785.25
|
| Rate for Payer: Cigna Commercial |
$4,623.52
|
| Rate for Payer: First Health Commercial |
$5,291.98
|
| Rate for Payer: Humana Commercial |
$4,734.92
|
| Rate for Payer: Humana KY Medicaid |
$1,915.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,935.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,567.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,954.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,177.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,114.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,726.86
|
| Rate for Payer: PHCS Commercial |
$5,347.68
|
| Rate for Payer: United Healthcare All Payer |
$4,902.04
|
|
|
BREAST IMP HIGH PROFILE 325CC
|
Facility
|
OP
|
$5,570.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$5,347.68 |
| Rate for Payer: Aetna Commercial |
$4,289.28
|
| Rate for Payer: Anthem Medicaid |
$1,915.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,344.99
|
| Rate for Payer: Cash Price |
$2,785.25
|
| Rate for Payer: Cigna Commercial |
$4,623.52
|
| Rate for Payer: First Health Commercial |
$5,291.98
|
| Rate for Payer: Humana Commercial |
$4,734.92
|
| Rate for Payer: Humana KY Medicaid |
$1,915.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,935.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,567.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,954.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,177.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,114.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,726.86
|
| Rate for Payer: PHCS Commercial |
$5,347.68
|
| Rate for Payer: United Healthcare All Payer |
$4,902.04
|
|
|
BREAST IMP HIGH PROFILE 325CC
|
Facility
|
IP
|
$5,570.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$5,347.68 |
| Rate for Payer: Aetna Commercial |
$4,289.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,344.99
|
| Rate for Payer: Cash Price |
$2,785.25
|
| Rate for Payer: Cigna Commercial |
$4,623.52
|
| Rate for Payer: First Health Commercial |
$5,291.98
|
| Rate for Payer: Humana Commercial |
$4,734.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,567.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,177.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,114.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,726.86
|
| Rate for Payer: PHCS Commercial |
$5,347.68
|
| Rate for Payer: United Healthcare All Payer |
$4,902.04
|
|
|
BREAST IMP HIGH PROFILE 350CC
|
Facility
|
OP
|
$5,570.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$5,347.68 |
| Rate for Payer: Aetna Commercial |
$4,289.28
|
| Rate for Payer: Anthem Medicaid |
$1,915.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,344.99
|
| Rate for Payer: Cash Price |
$2,785.25
|
| Rate for Payer: Cigna Commercial |
$4,623.52
|
| Rate for Payer: First Health Commercial |
$5,291.98
|
| Rate for Payer: Humana Commercial |
$4,734.92
|
| Rate for Payer: Humana KY Medicaid |
$1,915.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,935.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,567.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,954.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,177.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,114.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,726.86
|
| Rate for Payer: PHCS Commercial |
$5,347.68
|
| Rate for Payer: United Healthcare All Payer |
$4,902.04
|
|
|
BREAST IMP HIGH PROFILE 350CC
|
Facility
|
IP
|
$5,570.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$5,347.68 |
| Rate for Payer: Aetna Commercial |
$4,289.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,344.99
|
| Rate for Payer: Cash Price |
$2,785.25
|
| Rate for Payer: Cigna Commercial |
$4,623.52
|
| Rate for Payer: First Health Commercial |
$5,291.98
|
| Rate for Payer: Humana Commercial |
$4,734.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,567.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,111.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,671.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,902.04
|
| Rate for Payer: Ohio Health Group HMO |
$4,177.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,114.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$724.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,726.86
|
| Rate for Payer: PHCS Commercial |
$5,347.68
|
| Rate for Payer: United Healthcare All Payer |
$4,902.04
|
|
|
BREAST IMP HIGH PROFILE 375CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 375CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 400CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 400CC
|
Facility
|
IP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
|
BREAST IMP HIGH PROFILE 425CC
|
Facility
|
OP
|
$4,125.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$536.25 |
| Max. Negotiated Rate |
$3,960.00 |
| Rate for Payer: Aetna Commercial |
$3,176.25
|
| Rate for Payer: Anthem Medicaid |
$1,418.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,217.50
|
| Rate for Payer: Cash Price |
$2,062.50
|
| Rate for Payer: Cigna Commercial |
$3,423.75
|
| Rate for Payer: First Health Commercial |
$3,918.75
|
| Rate for Payer: Humana Commercial |
$3,506.25
|
| Rate for Payer: Humana KY Medicaid |
$1,418.59
|
| Rate for Payer: Kentucky WC Medicaid |
$1,433.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,382.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,044.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,237.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,447.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,630.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,093.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$825.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$536.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,278.75
|
| Rate for Payer: PHCS Commercial |
$3,960.00
|
| Rate for Payer: United Healthcare All Payer |
$3,630.00
|
|
