|
DELTA HEAD 12/14 XL/+12 36MM
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
DELTA HEAD 12/14 XL/+12 36MM
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
DELTA HUMERAL STEM DIA 14
|
Facility
|
OP
|
$16,101.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,093.21 |
| Max. Negotiated Rate |
$15,457.54 |
| Rate for Payer: Aetna Commercial |
$12,398.23
|
| Rate for Payer: Anthem Medicaid |
$5,537.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,559.25
|
| Rate for Payer: Cash Price |
$8,050.80
|
| Rate for Payer: Cigna Commercial |
$13,364.33
|
| Rate for Payer: First Health Commercial |
$15,296.52
|
| Rate for Payer: Humana Commercial |
$13,686.36
|
| Rate for Payer: Humana KY Medicaid |
$5,537.34
|
| Rate for Payer: Kentucky WC Medicaid |
$5,593.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,203.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,882.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,830.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,648.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,169.41
|
| Rate for Payer: Ohio Health Group HMO |
$12,076.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,220.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,093.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,991.50
|
| Rate for Payer: PHCS Commercial |
$15,457.54
|
| Rate for Payer: United Healthcare All Payer |
$14,169.41
|
|
|
DELTA HUMERAL STEM DIA 14
|
Facility
|
IP
|
$16,101.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,093.21 |
| Max. Negotiated Rate |
$15,457.54 |
| Rate for Payer: Aetna Commercial |
$12,398.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,559.25
|
| Rate for Payer: Cash Price |
$8,050.80
|
| Rate for Payer: Cigna Commercial |
$13,364.33
|
| Rate for Payer: First Health Commercial |
$15,296.52
|
| Rate for Payer: Humana Commercial |
$13,686.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,203.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,882.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,830.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,169.41
|
| Rate for Payer: Ohio Health Group HMO |
$12,076.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,220.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,093.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,991.50
|
| Rate for Payer: PHCS Commercial |
$15,457.54
|
| Rate for Payer: United Healthcare All Payer |
$14,169.41
|
|
|
DELTA PREMIERON HUM CUP SZ 38
|
Facility
|
OP
|
$12,541.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.43 |
| Max. Negotiated Rate |
$12,040.13 |
| Rate for Payer: Aetna Commercial |
$9,657.19
|
| Rate for Payer: Anthem Medicaid |
$4,313.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,782.60
|
| Rate for Payer: Cash Price |
$6,270.90
|
| Rate for Payer: Cigna Commercial |
$10,409.69
|
| Rate for Payer: First Health Commercial |
$11,914.71
|
| Rate for Payer: Humana Commercial |
$10,660.53
|
| Rate for Payer: Humana KY Medicaid |
$4,313.13
|
| Rate for Payer: Kentucky WC Medicaid |
$4,357.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,284.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,255.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,762.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,399.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,036.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,406.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,508.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,887.96
|
| Rate for Payer: PHCS Commercial |
$12,040.13
|
| Rate for Payer: United Healthcare All Payer |
$11,036.78
|
|
|
DELTA PREMIERON HUM CUP SZ 38
|
Facility
|
IP
|
$12,541.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.43 |
| Max. Negotiated Rate |
$12,040.13 |
| Rate for Payer: Aetna Commercial |
$9,657.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,782.60
|
| Rate for Payer: Cash Price |
$6,270.90
|
| Rate for Payer: Cigna Commercial |
$10,409.69
|
| Rate for Payer: First Health Commercial |
$11,914.71
|
| Rate for Payer: Humana Commercial |
$10,660.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,284.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,255.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,762.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,036.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,406.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,508.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,887.96
|
| Rate for Payer: PHCS Commercial |
$12,040.13
|
| Rate for Payer: United Healthcare All Payer |
$11,036.78
|
|
|
DELTA PREMIERON HUM CUP SZ 42
|
Facility
|
OP
|
$12,541.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.43 |
| Max. Negotiated Rate |
$12,040.13 |
| Rate for Payer: Aetna Commercial |
$9,657.19
|
| Rate for Payer: Anthem Medicaid |
$4,313.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,782.60
|
| Rate for Payer: Cash Price |
$6,270.90
|
| Rate for Payer: Cigna Commercial |
$10,409.69
|
| Rate for Payer: First Health Commercial |
$11,914.71
|
| Rate for Payer: Humana Commercial |
$10,660.53
|
| Rate for Payer: Humana KY Medicaid |
$4,313.13
|
| Rate for Payer: Kentucky WC Medicaid |
$4,357.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,284.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,255.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,762.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,399.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,036.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,406.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,508.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,887.96
|
| Rate for Payer: PHCS Commercial |
$12,040.13
|
| Rate for Payer: United Healthcare All Payer |
$11,036.78
|
|
|
DELTA PREMIERON HUM CUP SZ 42
|
Facility
|
IP
|
$12,541.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,630.43 |
| Max. Negotiated Rate |
$12,040.13 |
| Rate for Payer: Aetna Commercial |
$9,657.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,782.60
|
| Rate for Payer: Cash Price |
$6,270.90
|
| Rate for Payer: Cigna Commercial |
$10,409.69
|
| Rate for Payer: First Health Commercial |
$11,914.71
|
| Rate for Payer: Humana Commercial |
$10,660.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,284.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,255.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,762.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,036.78
|
| Rate for Payer: Ohio Health Group HMO |
$9,406.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,508.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,630.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,887.96
|
| Rate for Payer: PHCS Commercial |
$12,040.13
|
| Rate for Payer: United Healthcare All Payer |
$11,036.78
|
|
|
DELTA PREMIERON HUM CUP SZ42+3
|
Facility
|
OP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem Medicaid |
$4,266.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Humana KY Medicaid |
$4,266.68
|
| Rate for Payer: Kentucky WC Medicaid |
$4,310.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,352.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
DELTA PREMIERON HUM CUP SZ42+3
|
Facility
|
IP
|
$12,406.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,612.88 |
| Max. Negotiated Rate |
$11,910.48 |
| Rate for Payer: Aetna Commercial |
$9,553.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,677.26
|
| Rate for Payer: Cash Price |
$6,203.38
|
| Rate for Payer: Cigna Commercial |
$10,297.60
|
| Rate for Payer: First Health Commercial |
$11,786.41
|
| Rate for Payer: Humana Commercial |
$10,545.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,173.54
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,156.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,722.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,917.94
|
| Rate for Payer: Ohio Health Group HMO |
$9,305.06
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,481.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,612.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,846.09
|
| Rate for Payer: PHCS Commercial |
$11,910.48
|
| Rate for Payer: United Healthcare All Payer |
$10,917.94
|
|
|
DELTA TS CER HEAD 12/14 28MM12
|
Facility
|
IP
|
$10,905.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.76 |
| Max. Negotiated Rate |
$10,469.64 |
| Rate for Payer: Aetna Commercial |
$8,397.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,506.58
|
| Rate for Payer: Cash Price |
$5,452.94
|
| Rate for Payer: Cigna Commercial |
$9,051.87
|
| Rate for Payer: First Health Commercial |
$10,360.58
|
| Rate for Payer: Humana Commercial |
$9,269.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,942.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,048.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,271.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,597.17
|
| Rate for Payer: Ohio Health Group HMO |
$8,179.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,181.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,380.82
|
| Rate for Payer: PHCS Commercial |
$10,469.64
|
| Rate for Payer: United Healthcare All Payer |
$9,597.17
|
|
|
DELTA TS CER HEAD 12/14 28MM12
|
Facility
|
OP
|
$10,905.87
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.76 |
| Max. Negotiated Rate |
$10,469.64 |
| Rate for Payer: Aetna Commercial |
$8,397.52
|
| Rate for Payer: Anthem Medicaid |
$3,750.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,506.58
|
| Rate for Payer: Cash Price |
$5,452.94
|
| Rate for Payer: Cigna Commercial |
$9,051.87
|
| Rate for Payer: First Health Commercial |
$10,360.58
|
| Rate for Payer: Humana Commercial |
$9,269.99
|
| Rate for Payer: Humana KY Medicaid |
$3,750.53
|
| Rate for Payer: Kentucky WC Medicaid |
$3,788.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,942.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,048.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,271.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,825.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,597.17
|
| Rate for Payer: Ohio Health Group HMO |
$8,179.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,181.17
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,417.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,380.82
|
| Rate for Payer: PHCS Commercial |
$10,469.64
|
| Rate for Payer: United Healthcare All Payer |
$9,597.17
|
|
|
DELTA TS CER HEAD 12/14 28MM+5
|
Facility
|
IP
|
$10,024.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.23 |
| Max. Negotiated Rate |
$9,623.82 |
| Rate for Payer: Aetna Commercial |
$7,719.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,819.35
|
| Rate for Payer: Cash Price |
$5,012.40
|
| Rate for Payer: Cigna Commercial |
$8,320.59
|
| Rate for Payer: First Health Commercial |
$9,523.57
|
| Rate for Payer: Humana Commercial |
$8,521.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,220.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,398.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,007.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,821.83
|
| Rate for Payer: Ohio Health Group HMO |
$7,518.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,004.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,303.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,107.69
|
| Rate for Payer: PHCS Commercial |
$9,623.82
|
| Rate for Payer: United Healthcare All Payer |
$8,821.83
|
|
|
DELTA TS CER HEAD 12/14 28MM+5
|
Facility
|
OP
|
$10,024.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,303.23 |
| Max. Negotiated Rate |
$9,623.82 |
| Rate for Payer: Aetna Commercial |
$7,719.10
|
| Rate for Payer: Anthem Medicaid |
$3,447.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,819.35
|
| Rate for Payer: Cash Price |
$5,012.40
|
| Rate for Payer: Cigna Commercial |
$8,320.59
|
| Rate for Payer: First Health Commercial |
$9,523.57
|
| Rate for Payer: Humana Commercial |
$8,521.09
|
| Rate for Payer: Humana KY Medicaid |
$3,447.53
|
| Rate for Payer: Kentucky WC Medicaid |
$3,482.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,220.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,398.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,007.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,516.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,821.83
|
| Rate for Payer: Ohio Health Group HMO |
$7,518.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,004.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,303.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,107.69
|
| Rate for Payer: PHCS Commercial |
$9,623.82
|
| Rate for Payer: United Healthcare All Payer |
$8,821.83
|
|
|
DELTA TS CER HEAD 12/14 36MM +
|
Facility
|
IP
|
$19,415.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.06 |
| Max. Negotiated Rate |
$18,639.24 |
| Rate for Payer: Aetna Commercial |
$14,950.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,144.39
|
| Rate for Payer: Cash Price |
$9,707.94
|
| Rate for Payer: Cigna Commercial |
$16,115.18
|
| Rate for Payer: First Health Commercial |
$18,445.09
|
| Rate for Payer: Humana Commercial |
$16,503.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,921.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,328.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,824.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,085.97
|
| Rate for Payer: Ohio Health Group HMO |
$14,561.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,883.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,524.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,018.92
|
| Rate for Payer: PHCS Commercial |
$18,639.24
|
| Rate for Payer: United Healthcare All Payer |
$17,085.97
|
|
|
DELTA TS CER HEAD 12/14 36MM +
|
Facility
|
OP
|
$19,415.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.06 |
| Max. Negotiated Rate |
$18,639.24 |
| Rate for Payer: Aetna Commercial |
$14,950.23
|
| Rate for Payer: Anthem Medicaid |
$6,677.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,144.39
|
| Rate for Payer: Cash Price |
$9,707.94
|
| Rate for Payer: Cigna Commercial |
$16,115.18
|
| Rate for Payer: First Health Commercial |
$18,445.09
|
| Rate for Payer: Humana Commercial |
$16,503.50
|
| Rate for Payer: Humana KY Medicaid |
$6,677.12
|
| Rate for Payer: Kentucky WC Medicaid |
$6,745.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,921.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,328.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,824.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,811.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,085.97
|
| Rate for Payer: Ohio Health Group HMO |
$14,561.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,883.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,524.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,018.92
|
| Rate for Payer: PHCS Commercial |
$18,639.24
|
| Rate for Payer: United Healthcare All Payer |
$17,085.97
|
|
|
DELTA TS CER HEAD 12/14 36MM12
|
Facility
|
IP
|
$21,177.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,753.08 |
| Max. Negotiated Rate |
$20,330.45 |
| Rate for Payer: Aetna Commercial |
$16,306.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,518.49
|
| Rate for Payer: Cash Price |
$10,588.77
|
| Rate for Payer: Cigna Commercial |
$17,577.37
|
| Rate for Payer: First Health Commercial |
$20,118.67
|
| Rate for Payer: Humana Commercial |
$18,000.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,365.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,629.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,353.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,636.24
|
| Rate for Payer: Ohio Health Group HMO |
$15,883.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,235.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,753.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,565.04
|
| Rate for Payer: PHCS Commercial |
$20,330.45
|
| Rate for Payer: United Healthcare All Payer |
$18,636.24
|
|
|
DELTA TS CER HEAD 12/14 36MM12
|
Facility
|
OP
|
$21,177.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,753.08 |
| Max. Negotiated Rate |
$20,330.45 |
| Rate for Payer: Aetna Commercial |
$16,306.71
|
| Rate for Payer: Anthem Medicaid |
$7,282.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,518.49
|
| Rate for Payer: Cash Price |
$10,588.77
|
| Rate for Payer: Cigna Commercial |
$17,577.37
|
| Rate for Payer: First Health Commercial |
$20,118.67
|
| Rate for Payer: Humana Commercial |
$18,000.92
|
| Rate for Payer: Humana KY Medicaid |
$7,282.96
|
| Rate for Payer: Kentucky WC Medicaid |
$7,357.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,365.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,629.03
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,353.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,429.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,636.24
|
| Rate for Payer: Ohio Health Group HMO |
$15,883.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,235.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,753.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,565.04
|
| Rate for Payer: PHCS Commercial |
$20,330.45
|
| Rate for Payer: United Healthcare All Payer |
$18,636.24
|
|
|
DELTA TS CER HEAD 12/14 36MM 8
|
Facility
|
IP
|
$19,415.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.06 |
| Max. Negotiated Rate |
$18,639.24 |
| Rate for Payer: Aetna Commercial |
$14,950.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,144.39
|
| Rate for Payer: Cash Price |
$9,707.94
|
| Rate for Payer: Cigna Commercial |
$16,115.18
|
| Rate for Payer: First Health Commercial |
$18,445.09
|
| Rate for Payer: Humana Commercial |
$16,503.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,921.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,328.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,824.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,085.97
|
| Rate for Payer: Ohio Health Group HMO |
$14,561.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,883.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,524.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,018.92
|
| Rate for Payer: PHCS Commercial |
$18,639.24
|
| Rate for Payer: United Healthcare All Payer |
$17,085.97
|
|
|
DELTA TS CER HEAD 12/14 36MM 8
|
Facility
|
OP
|
$19,415.88
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,524.06 |
| Max. Negotiated Rate |
$18,639.24 |
| Rate for Payer: Aetna Commercial |
$14,950.23
|
| Rate for Payer: Anthem Medicaid |
$6,677.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,144.39
|
| Rate for Payer: Cash Price |
$9,707.94
|
| Rate for Payer: Cigna Commercial |
$16,115.18
|
| Rate for Payer: First Health Commercial |
$18,445.09
|
| Rate for Payer: Humana Commercial |
$16,503.50
|
| Rate for Payer: Humana KY Medicaid |
$6,677.12
|
| Rate for Payer: Kentucky WC Medicaid |
$6,745.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,921.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,328.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,824.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,811.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,085.97
|
| Rate for Payer: Ohio Health Group HMO |
$14,561.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,883.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,524.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,018.92
|
| Rate for Payer: PHCS Commercial |
$18,639.24
|
| Rate for Payer: United Healthcare All Payer |
$17,085.97
|
|
|
DELTA TS CER HEAD 12/14 40M +1
|
Facility
|
OP
|
$11,683.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.83 |
| Max. Negotiated Rate |
$11,215.99 |
| Rate for Payer: Aetna Commercial |
$8,996.16
|
| Rate for Payer: Anthem Medicaid |
$4,017.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,112.99
|
| Rate for Payer: Cash Price |
$5,841.66
|
| Rate for Payer: Cigna Commercial |
$9,697.16
|
| Rate for Payer: First Health Commercial |
$11,099.15
|
| Rate for Payer: Humana Commercial |
$9,930.82
|
| Rate for Payer: Humana KY Medicaid |
$4,017.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,058.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,622.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,505.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,098.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,281.32
|
| Rate for Payer: Ohio Health Group HMO |
$8,762.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,336.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,621.83
|
| Rate for Payer: PHCS Commercial |
$11,215.99
|
| Rate for Payer: United Healthcare All Payer |
$10,281.32
|
|
|
DELTA TS CER HEAD 12/14 40M +1
|
Facility
|
IP
|
$11,683.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.83 |
| Max. Negotiated Rate |
$11,215.99 |
| Rate for Payer: Aetna Commercial |
$8,996.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,112.99
|
| Rate for Payer: Cash Price |
$5,841.66
|
| Rate for Payer: Cigna Commercial |
$9,697.16
|
| Rate for Payer: First Health Commercial |
$11,099.15
|
| Rate for Payer: Humana Commercial |
$9,930.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,622.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,505.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,281.32
|
| Rate for Payer: Ohio Health Group HMO |
$8,762.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,336.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,621.83
|
| Rate for Payer: PHCS Commercial |
$11,215.99
|
| Rate for Payer: United Healthcare All Payer |
$10,281.32
|
|
|
DELTA TS CER HEAD 12/14 40M +8
|
Facility
|
OP
|
$11,683.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.83 |
| Max. Negotiated Rate |
$11,215.99 |
| Rate for Payer: Aetna Commercial |
$8,996.16
|
| Rate for Payer: Anthem Medicaid |
$4,017.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,112.99
|
| Rate for Payer: Cash Price |
$5,841.66
|
| Rate for Payer: Cigna Commercial |
$9,697.16
|
| Rate for Payer: First Health Commercial |
$11,099.15
|
| Rate for Payer: Humana Commercial |
$9,930.82
|
| Rate for Payer: Humana KY Medicaid |
$4,017.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,058.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,622.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,505.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,098.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,281.32
|
| Rate for Payer: Ohio Health Group HMO |
$8,762.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,336.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,621.83
|
| Rate for Payer: PHCS Commercial |
$11,215.99
|
| Rate for Payer: United Healthcare All Payer |
$10,281.32
|
|
|
DELTA TS CER HEAD 12/14 40M +8
|
Facility
|
IP
|
$11,683.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.83 |
| Max. Negotiated Rate |
$11,215.99 |
| Rate for Payer: Aetna Commercial |
$8,996.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,112.99
|
| Rate for Payer: Cash Price |
$5,841.66
|
| Rate for Payer: Cigna Commercial |
$9,697.16
|
| Rate for Payer: First Health Commercial |
$11,099.15
|
| Rate for Payer: Humana Commercial |
$9,930.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,622.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,505.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,281.32
|
| Rate for Payer: Ohio Health Group HMO |
$8,762.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,336.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,621.83
|
| Rate for Payer: PHCS Commercial |
$11,215.99
|
| Rate for Payer: United Healthcare All Payer |
$10,281.32
|
|
|
DELTA TS CER HEAD 12/14 40MM +
|
Facility
|
OP
|
$11,683.32
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,518.83 |
| Max. Negotiated Rate |
$11,215.99 |
| Rate for Payer: Aetna Commercial |
$8,996.16
|
| Rate for Payer: Anthem Medicaid |
$4,017.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,112.99
|
| Rate for Payer: Cash Price |
$5,841.66
|
| Rate for Payer: Cigna Commercial |
$9,697.16
|
| Rate for Payer: First Health Commercial |
$11,099.15
|
| Rate for Payer: Humana Commercial |
$9,930.82
|
| Rate for Payer: Humana KY Medicaid |
$4,017.89
|
| Rate for Payer: Kentucky WC Medicaid |
$4,058.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,580.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,622.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,505.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,098.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,281.32
|
| Rate for Payer: Ohio Health Group HMO |
$8,762.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,336.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,518.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,621.83
|
| Rate for Payer: PHCS Commercial |
$11,215.99
|
| Rate for Payer: United Healthcare All Payer |
$10,281.32
|
|
