|
BRST IMP RD SIL STYLE 45 460CC
|
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
|
|
|
BRST IMP RD SIL STYLE 45 500CC
|
Facility
|
OP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem Medicaid |
$1,358.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Humana KY Medicaid |
$1,358.40
|
| Rate for Payer: Kentucky WC Medicaid |
$1,372.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,385.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
BRST IMP RD SIL STYLE 45 500CC
|
Facility
|
IP
|
$3,950.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$513.50 |
| Max. Negotiated Rate |
$3,792.00 |
| Rate for Payer: Aetna Commercial |
$3,041.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,081.00
|
| Rate for Payer: Cash Price |
$1,975.00
|
| Rate for Payer: Cigna Commercial |
$3,278.50
|
| Rate for Payer: First Health Commercial |
$3,752.50
|
| Rate for Payer: Humana Commercial |
$3,357.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,239.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,915.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,185.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,476.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,962.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$790.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$513.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.50
|
| Rate for Payer: PHCS Commercial |
$3,792.00
|
| Rate for Payer: United Healthcare All Payer |
$3,476.00
|
|
|
BRST IMP SALINE RND MOD+ 400CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SALINE RND MOD+ 400CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 550CC
|
Facility
|
IP
|
$5,612.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$729.62 |
| Max. Negotiated Rate |
$5,388.00 |
| Rate for Payer: Aetna Commercial |
$4,321.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,377.75
|
| Rate for Payer: Cash Price |
$2,806.25
|
| Rate for Payer: Cigna Commercial |
$4,658.38
|
| Rate for Payer: First Health Commercial |
$5,331.88
|
| Rate for Payer: Humana Commercial |
$4,770.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,602.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,142.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,683.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,939.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,209.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,739.88
|
| Rate for Payer: PHCS Commercial |
$5,388.00
|
| Rate for Payer: United Healthcare All Payer |
$4,939.00
|
|
|
BRST IMP SILTEX RD HIGH 550CC
|
Facility
|
OP
|
$5,612.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$729.62 |
| Max. Negotiated Rate |
$5,388.00 |
| Rate for Payer: Aetna Commercial |
$4,321.62
|
| Rate for Payer: Anthem Medicaid |
$1,930.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,377.75
|
| Rate for Payer: Cash Price |
$2,806.25
|
| Rate for Payer: Cigna Commercial |
$4,658.38
|
| Rate for Payer: First Health Commercial |
$5,331.88
|
| Rate for Payer: Humana Commercial |
$4,770.62
|
| Rate for Payer: Humana KY Medicaid |
$1,930.14
|
| Rate for Payer: Kentucky WC Medicaid |
$1,949.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,602.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,142.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,683.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,968.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,939.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,209.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,122.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$729.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,739.88
|
| Rate for Payer: PHCS Commercial |
$5,388.00
|
| Rate for Payer: United Healthcare All Payer |
$4,939.00
|
|
|
BRST IMP SILTEX RD HIGH 600CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 600CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 650CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 650CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 700CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 700CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 750CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 750CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 800CC
|
Facility
|
OP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem Medicaid |
$1,900.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Humana KY Medicaid |
$1,900.05
|
| Rate for Payer: Kentucky WC Medicaid |
$1,919.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,938.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD HIGH 800CC
|
Facility
|
IP
|
$5,525.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$718.25 |
| Max. Negotiated Rate |
$5,304.00 |
| Rate for Payer: Aetna Commercial |
$4,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,309.50
|
| Rate for Payer: Cash Price |
$2,762.50
|
| Rate for Payer: Cigna Commercial |
$4,585.75
|
| Rate for Payer: First Health Commercial |
$5,248.75
|
| Rate for Payer: Humana Commercial |
$4,696.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,530.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,077.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,657.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,862.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,143.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,105.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$718.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,712.75
|
| Rate for Payer: PHCS Commercial |
$5,304.00
|
| Rate for Payer: United Healthcare All Payer |
$4,862.00
|
|
|
BRST IMP SILTEX RD MOD+ 400CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 400CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 425CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 425CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 450CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 450CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 475CC
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
BRST IMP SILTEX RD MOD+ 475CC
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
