|
TRI RM/LL TIB AUG SZ 4 10MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 4 5MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 4 5MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 5 10MM
|
Facility
|
IP
|
$7,537.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.90 |
| Max. Negotiated Rate |
$7,236.19 |
| Rate for Payer: Aetna Commercial |
$5,804.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,879.41
|
| Rate for Payer: Cash Price |
$3,768.85
|
| Rate for Payer: Cigna Commercial |
$6,256.29
|
| Rate for Payer: First Health Commercial |
$7,160.82
|
| Rate for Payer: Humana Commercial |
$6,407.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,180.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,562.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,261.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,633.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,653.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,507.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$979.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,336.69
|
| Rate for Payer: PHCS Commercial |
$7,236.19
|
| Rate for Payer: United Healthcare All Payer |
$6,633.18
|
|
|
TRI RM/LL TIB AUG SZ 5 10MM
|
Facility
|
OP
|
$7,537.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$979.90 |
| Max. Negotiated Rate |
$7,236.19 |
| Rate for Payer: Aetna Commercial |
$5,804.03
|
| Rate for Payer: Anthem Medicaid |
$2,592.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,879.41
|
| Rate for Payer: Cash Price |
$3,768.85
|
| Rate for Payer: Cigna Commercial |
$6,256.29
|
| Rate for Payer: First Health Commercial |
$7,160.82
|
| Rate for Payer: Humana Commercial |
$6,407.04
|
| Rate for Payer: Humana KY Medicaid |
$2,592.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,618.60
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,180.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,562.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,261.31
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,644.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,633.18
|
| Rate for Payer: Ohio Health Group HMO |
$5,653.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,507.54
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$979.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,336.69
|
| Rate for Payer: PHCS Commercial |
$7,236.19
|
| Rate for Payer: United Healthcare All Payer |
$6,633.18
|
|
|
TRI RM/LL TIB AUG SZ 5 5MM
|
Facility
|
IP
|
$7,048.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$916.32 |
| Max. Negotiated Rate |
$6,766.66 |
| Rate for Payer: Aetna Commercial |
$5,427.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,497.91
|
| Rate for Payer: Cash Price |
$3,524.30
|
| Rate for Payer: Cigna Commercial |
$5,850.34
|
| Rate for Payer: First Health Commercial |
$6,696.17
|
| Rate for Payer: Humana Commercial |
$5,991.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,779.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,201.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,114.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,202.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,286.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,409.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$916.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,185.07
|
| Rate for Payer: PHCS Commercial |
$6,766.66
|
| Rate for Payer: United Healthcare All Payer |
$6,202.77
|
|
|
TRI RM/LL TIB AUG SZ 5 5MM
|
Facility
|
OP
|
$7,048.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$916.32 |
| Max. Negotiated Rate |
$6,766.66 |
| Rate for Payer: Aetna Commercial |
$5,427.42
|
| Rate for Payer: Anthem Medicaid |
$2,424.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,497.91
|
| Rate for Payer: Cash Price |
$3,524.30
|
| Rate for Payer: Cigna Commercial |
$5,850.34
|
| Rate for Payer: First Health Commercial |
$6,696.17
|
| Rate for Payer: Humana Commercial |
$5,991.31
|
| Rate for Payer: Humana KY Medicaid |
$2,424.01
|
| Rate for Payer: Kentucky WC Medicaid |
$2,448.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,779.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,201.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,114.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,472.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,202.77
|
| Rate for Payer: Ohio Health Group HMO |
$5,286.45
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,409.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$916.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,185.07
|
| Rate for Payer: PHCS Commercial |
$6,766.66
|
| Rate for Payer: United Healthcare All Payer |
$6,202.77
|
|
|
TRI RM/LL TIB AUG SZ 6 10MM
|
Facility
|
OP
|
$6,805.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.68 |
| Max. Negotiated Rate |
$6,533.04 |
| Rate for Payer: Aetna Commercial |
$5,240.04
|
| Rate for Payer: Anthem Medicaid |
$2,340.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,308.10
|
| Rate for Payer: Cash Price |
$3,402.63
|
| Rate for Payer: Cigna Commercial |
$5,648.36
|
| Rate for Payer: First Health Commercial |
$6,464.99
|
| Rate for Payer: Humana Commercial |
$5,784.46
|
| Rate for Payer: Humana KY Medicaid |
$2,340.33
|
| Rate for Payer: Kentucky WC Medicaid |
$2,364.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,580.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,022.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,041.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,387.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,988.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,103.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,361.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$884.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,109.63
|
| Rate for Payer: PHCS Commercial |
$6,533.04
|
| Rate for Payer: United Healthcare All Payer |
$5,988.62
|
|
|
TRI RM/LL TIB AUG SZ 6 10MM
|
Facility
|
IP
|
$6,805.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$884.68 |
| Max. Negotiated Rate |
$6,533.04 |
| Rate for Payer: Aetna Commercial |
$5,240.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,308.10
|
| Rate for Payer: Cash Price |
$3,402.63
|
| Rate for Payer: Cigna Commercial |
$5,648.36
|
| Rate for Payer: First Health Commercial |
$6,464.99
|
| Rate for Payer: Humana Commercial |
$5,784.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,580.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,022.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,041.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,988.62
|
| Rate for Payer: Ohio Health Group HMO |
$5,103.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,361.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$884.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,109.63
|
| Rate for Payer: PHCS Commercial |
$6,533.04
|
| Rate for Payer: United Healthcare All Payer |
$5,988.62
|
|
|
TRI RM/LL TIB AUG SZ 6 5MM
|
Facility
|
OP
|
$7,805.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.68 |
| Max. Negotiated Rate |
$7,493.03 |
| Rate for Payer: Aetna Commercial |
$6,010.03
|
| Rate for Payer: Anthem Medicaid |
$2,684.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,088.09
|
| Rate for Payer: Cash Price |
$3,902.62
|
| Rate for Payer: Cigna Commercial |
$6,478.35
|
| Rate for Payer: First Health Commercial |
$7,414.98
|
| Rate for Payer: Humana Commercial |
$6,634.45
|
| Rate for Payer: Humana KY Medicaid |
$2,684.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,711.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,400.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,760.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,738.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.61
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,561.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,014.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,419.62
|
| Rate for Payer: PHCS Commercial |
$7,493.03
|
| Rate for Payer: United Healthcare All Payer |
$6,868.61
|
|
|
TRI RM/LL TIB AUG SZ 6 5MM
|
Facility
|
IP
|
$7,805.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,014.68 |
| Max. Negotiated Rate |
$7,493.03 |
| Rate for Payer: Aetna Commercial |
$6,010.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,088.09
|
| Rate for Payer: Cash Price |
$3,902.62
|
| Rate for Payer: Cigna Commercial |
$6,478.35
|
| Rate for Payer: First Health Commercial |
$7,414.98
|
| Rate for Payer: Humana Commercial |
$6,634.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,400.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,760.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,341.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,868.61
|
| Rate for Payer: Ohio Health Group HMO |
$5,853.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,561.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,014.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,419.62
|
| Rate for Payer: PHCS Commercial |
$7,493.03
|
| Rate for Payer: United Healthcare All Payer |
$6,868.61
|
|
|
TRI RM/LL TIB AUG SZ 7 10MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 7 10MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 7 5MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 7 5MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 8 10MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 8 10MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 8 5MM
|
Facility
|
OP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem Medicaid |
$2,554.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Humana KY Medicaid |
$2,554.56
|
| Rate for Payer: Kentucky WC Medicaid |
$2,580.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,605.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRI RM/LL TIB AUG SZ 8 5MM
|
Facility
|
IP
|
$7,428.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$965.67 |
| Max. Negotiated Rate |
$7,131.07 |
| Rate for Payer: Aetna Commercial |
$5,719.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,794.00
|
| Rate for Payer: Cash Price |
$3,714.10
|
| Rate for Payer: Cigna Commercial |
$6,165.41
|
| Rate for Payer: First Health Commercial |
$7,056.79
|
| Rate for Payer: Humana Commercial |
$6,313.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,091.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,482.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,228.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,536.82
|
| Rate for Payer: Ohio Health Group HMO |
$5,571.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,485.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$965.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,302.74
|
| Rate for Payer: PHCS Commercial |
$7,131.07
|
| Rate for Payer: United Healthcare All Payer |
$6,536.82
|
|
|
TRISENOX 1MG[10MG/10ML AMP
|
Facility
|
OP
|
$3,064.21
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
25002558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.78 |
| Max. Negotiated Rate |
$2,941.64 |
| Rate for Payer: Aetna Commercial |
$2,359.44
|
| Rate for Payer: Anthem Medicaid |
$1,053.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$15.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,390.08
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$22.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$21.31
|
| Rate for Payer: Cash Price |
$1,532.11
|
| Rate for Payer: Cash Price |
$1,532.11
|
| Rate for Payer: Cigna Commercial |
$2,543.29
|
| Rate for Payer: First Health Commercial |
$2,911.00
|
| Rate for Payer: Humana Commercial |
$2,604.58
|
| Rate for Payer: Humana KY Medicaid |
$1,053.78
|
| Rate for Payer: Humana Medicare Advantage |
$15.78
|
| Rate for Payer: Kentucky WC Medicaid |
$1,064.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,512.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,261.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,074.92
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,696.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,298.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$612.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$398.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$949.91
|
| Rate for Payer: PHCS Commercial |
$2,941.64
|
| Rate for Payer: United Healthcare All Payer |
$2,696.50
|
|
|
TRISENOX 1MG[10MG/10ML AMP
|
Facility
|
IP
|
$3,064.21
|
|
|
Service Code
|
HCPCS J9017
|
| Hospital Charge Code |
25002558
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$398.35 |
| Max. Negotiated Rate |
$2,941.64 |
| Rate for Payer: Aetna Commercial |
$2,359.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,390.08
|
| Rate for Payer: Cash Price |
$1,532.11
|
| Rate for Payer: Cigna Commercial |
$2,543.29
|
| Rate for Payer: First Health Commercial |
$2,911.00
|
| Rate for Payer: Humana Commercial |
$2,604.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,512.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,261.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$919.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,696.50
|
| Rate for Payer: Ohio Health Group HMO |
$2,298.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$612.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$398.35
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$949.91
|
| Rate for Payer: PHCS Commercial |
$2,941.64
|
| Rate for Payer: United Healthcare All Payer |
$2,696.50
|
|
|
TRITANIUM HEMI CLUSTER SHELL 4
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
TRITANIUM HEMI CLUSTER SHELL 4
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
TRITANIUM HEMI CLUSTER SHELL 5
|
Facility
|
IP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
|
TRITANIUM HEMI CLUSTER SHELL 5
|
Facility
|
OP
|
$11,111.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,444.43 |
| Max. Negotiated Rate |
$10,666.56 |
| Rate for Payer: Aetna Commercial |
$8,555.47
|
| Rate for Payer: Anthem Medicaid |
$3,821.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,666.58
|
| Rate for Payer: Cash Price |
$5,555.50
|
| Rate for Payer: Cigna Commercial |
$9,222.13
|
| Rate for Payer: First Health Commercial |
$10,555.45
|
| Rate for Payer: Humana Commercial |
$9,444.35
|
| Rate for Payer: Humana KY Medicaid |
$3,821.07
|
| Rate for Payer: Kentucky WC Medicaid |
$3,859.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,111.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,199.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,333.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,897.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,777.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,333.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,222.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,444.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,444.41
|
| Rate for Payer: PHCS Commercial |
$10,666.56
|
| Rate for Payer: United Healthcare All Payer |
$9,777.68
|
|
