|
SULFADIAZINE 500MG TABLET
|
Facility
|
OP
|
$33.03
|
|
|
Service Code
|
NDC 42806075760
|
| Hospital Charge Code |
25001450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$31.71 |
| Rate for Payer: Aetna Commercial |
$25.43
|
| Rate for Payer: Anthem Medicaid |
$11.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.76
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cigna Commercial |
$27.41
|
| Rate for Payer: First Health Commercial |
$31.38
|
| Rate for Payer: Humana Commercial |
$28.08
|
| Rate for Payer: Humana KY Medicaid |
$11.36
|
| Rate for Payer: Kentucky WC Medicaid |
$11.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.07
|
| Rate for Payer: Ohio Health Group HMO |
$24.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.79
|
| Rate for Payer: PHCS Commercial |
$31.71
|
| Rate for Payer: United Healthcare All Payer |
$29.07
|
|
|
SULFADIAZINE 500MG TABLET
|
Facility
|
IP
|
$33.03
|
|
|
Service Code
|
NDC 42806075760
|
| Hospital Charge Code |
25001450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$31.71 |
| Rate for Payer: Aetna Commercial |
$25.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$25.76
|
| Rate for Payer: Cash Price |
$16.52
|
| Rate for Payer: Cigna Commercial |
$27.41
|
| Rate for Payer: First Health Commercial |
$31.38
|
| Rate for Payer: Humana Commercial |
$28.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.07
|
| Rate for Payer: Ohio Health Group HMO |
$24.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$26.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$28.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$22.79
|
| Rate for Payer: PHCS Commercial |
$31.71
|
| Rate for Payer: United Healthcare All Payer |
$29.07
|
|
|
SULFASALAZINE EC 500 MG TABLET
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
25001452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
SULFASALAZINE EC 500 MG TABLET
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
NDC 59762010405
|
| Hospital Charge Code |
25001452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.31 |
| Rate for Payer: Aetna Commercial |
$3.46
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.50
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cigna Commercial |
$3.73
|
| Rate for Payer: First Health Commercial |
$4.27
|
| Rate for Payer: Humana Commercial |
$3.82
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.95
|
| Rate for Payer: Ohio Health Group HMO |
$3.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.10
|
| Rate for Payer: PHCS Commercial |
$4.31
|
| Rate for Payer: United Healthcare All Payer |
$3.95
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 3
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 3
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 4
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 4
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 5
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 5
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 6
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 6
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 7
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 7
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 8
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM HI OFFSET SZ 8
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFSET SZ
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFSET SZ
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 4
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 4
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 5
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 5
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 6
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 6
|
Facility
|
OP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem Medicaid |
$5,473.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Humana KY Medicaid |
$5,473.98
|
| Rate for Payer: Kentucky WC Medicaid |
$5,529.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,583.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
|
SUMMIT CEM STEM STD OFFST SZ 7
|
Facility
|
IP
|
$15,917.36
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,775.21 |
| Max. Negotiated Rate |
$15,280.67 |
| Rate for Payer: Aetna Commercial |
$12,256.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,415.54
|
| Rate for Payer: Cash Price |
$7,958.68
|
| Rate for Payer: Cigna Commercial |
$13,211.41
|
| Rate for Payer: First Health Commercial |
$15,121.49
|
| Rate for Payer: Humana Commercial |
$13,529.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,052.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,747.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,775.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,007.28
|
| Rate for Payer: Ohio Health Group HMO |
$11,938.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,733.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,848.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,982.98
|
| Rate for Payer: PHCS Commercial |
$15,280.67
|
| Rate for Payer: United Healthcare All Payer |
$14,007.28
|
|
