|
BREAST IMP INSPIRA STY MOD 485
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST IMP INSPIRA STY MOD 485
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST IMP INSPIRA STY MOD 520
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA STY MOD 520
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA STY MOD 560
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA STY MOD 560
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 445C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 445C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 470C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 470C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 495C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 495C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 525C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 525C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 545C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 545C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 560C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 560C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 580C
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST IMP INSPIRA X-FULL 580C
|
Facility
|
OP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem Medicaid |
$1,461.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Humana KY Medicaid |
$1,461.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,476.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,490.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
|
BREAST IMP INSPIRA X-FULL 615C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 615C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 650C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 650C
|
Facility
|
OP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem Medicaid |
$2,320.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Humana KY Medicaid |
$2,320.83
|
| Rate for Payer: Kentucky WC Medicaid |
$2,344.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,367.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
|
BREAST IMP INSPIRA X-FULL 700C
|
Facility
|
IP
|
$6,748.55
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,024.57 |
| Max. Negotiated Rate |
$6,478.61 |
| Rate for Payer: Aetna Commercial |
$5,196.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,263.87
|
| Rate for Payer: Cash Price |
$3,374.28
|
| Rate for Payer: Cigna Commercial |
$5,601.30
|
| Rate for Payer: First Health Commercial |
$6,411.12
|
| Rate for Payer: Humana Commercial |
$5,736.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,533.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,980.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,024.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,938.72
|
| Rate for Payer: Ohio Health Group HMO |
$5,061.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,398.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,871.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,656.50
|
| Rate for Payer: PHCS Commercial |
$6,478.61
|
| Rate for Payer: United Healthcare All Payer |
$5,938.72
|
|
