|
BREAST IMP MOD SMTH COHESIVE 4
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Aetna Commercial |
$6,253.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,334.34
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cash Price |
$4,060.48
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: Cigna Commercial |
$6,740.39
|
| Rate for Payer: First Health Commercial |
$7,714.90
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$6,902.81
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,659.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,993.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,436.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,146.44
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group HMO |
$6,090.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,496.76
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,065.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,603.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: PHCS Commercial |
$7,796.11
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
| Rate for Payer: United Healthcare All Payer |
$7,146.44
|
|
|
BREAST IMP MOD SMTH COHESIVE 5
|
Facility
|
OP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem Medicaid |
$1,912.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Humana KY Medicaid |
$1,912.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,932.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,951.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BREAST IMP MOD SMTH COHESIVE 5
|
Facility
|
IP
|
$5,562.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,668.75 |
| Max. Negotiated Rate |
$5,340.00 |
| Rate for Payer: Aetna Commercial |
$4,283.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,338.75
|
| Rate for Payer: Cash Price |
$2,781.25
|
| Rate for Payer: Cigna Commercial |
$4,616.88
|
| Rate for Payer: First Health Commercial |
$5,284.38
|
| Rate for Payer: Humana Commercial |
$4,728.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,561.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,105.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,668.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,895.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,171.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,450.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,839.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,838.12
|
| Rate for Payer: PHCS Commercial |
$5,340.00
|
| Rate for Payer: United Healthcare All Payer |
$4,895.00
|
|
|
BREAST IMP MOD SMTH SFT TCH 27
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 27
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 29
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 29
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 31
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 31
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 33
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 33
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 34
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 34
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 36
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 36
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 37
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 37
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 40
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 40
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 44
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 44
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 48
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 48
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 52
|
Facility
|
IP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
|
BREAST IMP MOD SMTH SFT TCH 52
|
Facility
|
OP
|
$7,927.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,378.25 |
| Max. Negotiated Rate |
$7,610.40 |
| Rate for Payer: Aetna Commercial |
$6,104.18
|
| Rate for Payer: Anthem Medicaid |
$2,726.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,183.45
|
| Rate for Payer: Cash Price |
$3,963.75
|
| Rate for Payer: Cigna Commercial |
$6,579.82
|
| Rate for Payer: First Health Commercial |
$7,531.12
|
| Rate for Payer: Humana Commercial |
$6,738.38
|
| Rate for Payer: Humana KY Medicaid |
$2,726.27
|
| Rate for Payer: Kentucky WC Medicaid |
$2,754.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,500.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,850.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,378.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,780.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,976.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,945.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,342.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,896.93
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,469.98
|
| Rate for Payer: PHCS Commercial |
$7,610.40
|
| Rate for Payer: United Healthcare All Payer |
$6,976.20
|
|
