|
BREAST IMP X-FL SMTH SFT TCH 7
|
Facility
|
IP
|
$7,727.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,004.58 |
| Max. Negotiated Rate |
$7,418.40 |
| Rate for Payer: Aetna Commercial |
$5,950.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,027.45
|
| Rate for Payer: Cash Price |
$3,863.75
|
| Rate for Payer: Cigna Commercial |
$6,413.82
|
| Rate for Payer: First Health Commercial |
$7,341.12
|
| Rate for Payer: Humana Commercial |
$6,568.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,336.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,702.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,318.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,800.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,795.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,545.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,004.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,395.52
|
| Rate for Payer: PHCS Commercial |
$7,418.40
|
| Rate for Payer: United Healthcare All Payer |
$6,800.20
|
|
|
BREAST MEMORYSHAPE L MOD+145CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+145CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+170CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+170CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+195CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+195CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+225CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+225CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+255CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+255CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+290CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE L MOD+290CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+140CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+140CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+165CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+165CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+195CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+195CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+225CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+225CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+255CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+255CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+295CC
|
Facility
|
OP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem Medicaid |
$2,745.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Humana KY Medicaid |
$2,745.35
|
| Rate for Payer: Kentucky WC Medicaid |
$2,773.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,800.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
|
BREAST MEMORYSHAPE M MOD+295CC
|
Facility
|
IP
|
$7,983.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,037.79 |
| Max. Negotiated Rate |
$7,663.68 |
| Rate for Payer: Aetna Commercial |
$6,146.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,226.74
|
| Rate for Payer: Cash Price |
$3,991.50
|
| Rate for Payer: Cigna Commercial |
$6,625.89
|
| Rate for Payer: First Health Commercial |
$7,583.85
|
| Rate for Payer: Humana Commercial |
$6,785.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,546.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,891.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,394.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,025.04
|
| Rate for Payer: Ohio Health Group HMO |
$5,987.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,596.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,037.79
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,474.73
|
| Rate for Payer: PHCS Commercial |
$7,663.68
|
| Rate for Payer: United Healthcare All Payer |
$7,025.04
|
|
