|
BREAST IMP MOD PROFILE 420CC
|
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 MOD PROFILE 420CC
|
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 MOD+ PROFILE 421CC
|
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 MOD+ PROFILE 421CC
|
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 MOD PROFILE 450CC
|
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 MOD PROFILE 450CC
|
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 MOD+ PROFILE 457CC
|
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 MOD+ PROFILE 457CC
|
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 MOD PROFILE 480CC
|
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 MOD PROFILE 480CC
|
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 MOD+ PROFILE 492CC
|
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 MOD+ PROFILE 492CC
|
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 MOD PROFILE 510CC
|
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 MOD PROFILE 510CC
|
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 MOD+ PROFILE 533CC
|
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 MOD+ PROFILE 533CC
|
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 MOD PROFILE 550CC
|
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 MOD PROFILE 550CC
|
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 MOD+ PROFILE 575CC
|
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 MOD+ PROFILE 575CC
|
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 MOD PROFILE 600CC
|
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 MOD PROFILE 600CC
|
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 MOD+ PROFILE 616CC
|
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 MOD+ PROFILE 616CC
|
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 MOD PROFILE 650CC
|
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
|
|
