|
DELSYM 30 MG/5ML SUSPENSION
|
Facility
|
IP
|
$4.54
|
|
|
Service Code
|
NDC 904631256
|
| Hospital Charge Code |
25000525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
DELSYM 30 MG/5ML SUSPENSION
|
Facility
|
OP
|
$4.54
|
|
|
Service Code
|
NDC 904631256
|
| Hospital Charge Code |
25000525
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$4.36 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Anthem Medicaid |
$1.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Cash Price |
$2.27
|
| Rate for Payer: Cigna Commercial |
$3.77
|
| Rate for Payer: First Health Commercial |
$4.31
|
| Rate for Payer: Humana Commercial |
$3.86
|
| Rate for Payer: Humana KY Medicaid |
$1.56
|
| Rate for Payer: Kentucky WC Medicaid |
$1.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.00
|
| Rate for Payer: Ohio Health Group HMO |
$3.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Payer |
$4.00
|
|
|
DELTA CER HEAD +0 36MM 11/13
|
Facility
|
OP
|
$9,983.91
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,995.17 |
| Max. Negotiated Rate |
$9,584.55 |
| Rate for Payer: Aetna Commercial |
$7,687.61
|
| Rate for Payer: Anthem Medicaid |
$3,433.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,787.45
|
| Rate for Payer: Cash Price |
$4,991.96
|
| Rate for Payer: Cigna Commercial |
$8,286.65
|
| Rate for Payer: First Health Commercial |
$9,484.71
|
| Rate for Payer: Humana Commercial |
$8,486.32
|
| Rate for Payer: Humana KY Medicaid |
$3,433.47
|
| Rate for Payer: Kentucky WC Medicaid |
$3,468.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,186.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,368.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,995.17
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,502.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,785.84
|
| Rate for Payer: Ohio Health Group HMO |
$7,487.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,987.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,686.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,888.90
|
| Rate for Payer: PHCS Commercial |
$9,584.55
|
| Rate for Payer: United Healthcare All Payer |
$8,785.84
|
|
|
DELTA CER HEAD +0 36MM 11/13
|
Facility
|
IP
|
$9,983.91
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,995.17 |
| Max. Negotiated Rate |
$9,584.55 |
| Rate for Payer: Aetna Commercial |
$7,687.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,787.45
|
| Rate for Payer: Cash Price |
$4,991.96
|
| Rate for Payer: Cigna Commercial |
$8,286.65
|
| Rate for Payer: First Health Commercial |
$9,484.71
|
| Rate for Payer: Humana Commercial |
$8,486.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,186.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,368.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,995.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,785.84
|
| Rate for Payer: Ohio Health Group HMO |
$7,487.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,987.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,686.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,888.90
|
| Rate for Payer: PHCS Commercial |
$9,584.55
|
| Rate for Payer: United Healthcare All Payer |
$8,785.84
|
|
|
DELTA CER HEAD 11/13 28MM +0
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 28MM +0
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 28MM +3
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 28MM +3
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 28MM +6
|
Facility
|
OP
|
$10,224.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,067.44 |
| Max. Negotiated Rate |
$9,815.82 |
| Rate for Payer: Aetna Commercial |
$7,873.10
|
| Rate for Payer: Anthem Medicaid |
$3,516.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,975.35
|
| Rate for Payer: Cash Price |
$5,112.40
|
| Rate for Payer: Cigna Commercial |
$8,486.59
|
| Rate for Payer: First Health Commercial |
$9,713.57
|
| Rate for Payer: Humana Commercial |
$8,691.09
|
| Rate for Payer: Humana KY Medicaid |
$3,516.31
|
| Rate for Payer: Kentucky WC Medicaid |
$3,552.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,384.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,545.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,067.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,586.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,997.83
|
| Rate for Payer: Ohio Health Group HMO |
$7,668.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,179.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,895.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,055.12
|
| Rate for Payer: PHCS Commercial |
$9,815.82
|
| Rate for Payer: United Healthcare All Payer |
$8,997.83
|
|
|
DELTA CER HEAD 11/13 28MM +6
|
Facility
|
IP
|
$10,224.81
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,067.44 |
| Max. Negotiated Rate |
$9,815.82 |
| Rate for Payer: Aetna Commercial |
$7,873.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,975.35
|
| Rate for Payer: Cash Price |
$5,112.40
|
| Rate for Payer: Cigna Commercial |
$8,486.59
|
| Rate for Payer: First Health Commercial |
$9,713.57
|
| Rate for Payer: Humana Commercial |
$8,691.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,384.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,545.91
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,067.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,997.83
|
| Rate for Payer: Ohio Health Group HMO |
$7,668.61
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,179.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,895.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,055.12
|
| Rate for Payer: PHCS Commercial |
$9,815.82
|
| Rate for Payer: United Healthcare All Payer |
$8,997.83
|
|
|
DELTA CER HEAD 11/13 32MM +0
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 32MM +0
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 32MM +3
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 32MM +3
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 11/13 32MM +6
|
Facility
|
IP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
DELTA CER HEAD 11/13 32MM +6
|
Facility
|
OP
|
$9,620.37
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,886.11 |
| Max. Negotiated Rate |
$9,235.56 |
| Rate for Payer: Aetna Commercial |
$7,407.68
|
| Rate for Payer: Anthem Medicaid |
$3,308.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,503.89
|
| Rate for Payer: Cash Price |
$4,810.19
|
| Rate for Payer: Cigna Commercial |
$7,984.91
|
| Rate for Payer: First Health Commercial |
$9,139.35
|
| Rate for Payer: Humana Commercial |
$8,177.31
|
| Rate for Payer: Humana KY Medicaid |
$3,308.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3,342.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,888.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,099.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,886.11
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,374.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,465.93
|
| Rate for Payer: Ohio Health Group HMO |
$7,215.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,696.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,369.72
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,638.06
|
| Rate for Payer: PHCS Commercial |
$9,235.56
|
| Rate for Payer: United Healthcare All Payer |
$8,465.93
|
|
|
DELTA CER HEAD 12/14 28MM +1.5
|
Facility
|
OP
|
$9,089.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,726.98 |
| Max. Negotiated Rate |
$8,726.32 |
| Rate for Payer: Aetna Commercial |
$6,999.24
|
| Rate for Payer: Anthem Medicaid |
$3,126.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,090.14
|
| Rate for Payer: Cash Price |
$4,544.96
|
| Rate for Payer: Cigna Commercial |
$7,544.63
|
| Rate for Payer: First Health Commercial |
$8,635.42
|
| Rate for Payer: Humana Commercial |
$7,726.43
|
| Rate for Payer: Humana KY Medicaid |
$3,126.02
|
| Rate for Payer: Kentucky WC Medicaid |
$3,157.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,453.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,708.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,726.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,188.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,999.13
|
| Rate for Payer: Ohio Health Group HMO |
$6,817.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,271.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,908.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,272.04
|
| Rate for Payer: PHCS Commercial |
$8,726.32
|
| Rate for Payer: United Healthcare All Payer |
$7,999.13
|
|
|
DELTA CER HEAD 12/14 28MM +1.5
|
Facility
|
IP
|
$9,089.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,726.98 |
| Max. Negotiated Rate |
$8,726.32 |
| Rate for Payer: Aetna Commercial |
$6,999.24
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,090.14
|
| Rate for Payer: Cash Price |
$4,544.96
|
| Rate for Payer: Cigna Commercial |
$7,544.63
|
| Rate for Payer: First Health Commercial |
$8,635.42
|
| Rate for Payer: Humana Commercial |
$7,726.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,453.73
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,708.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,726.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,999.13
|
| Rate for Payer: Ohio Health Group HMO |
$6,817.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,271.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,908.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,272.04
|
| Rate for Payer: PHCS Commercial |
$8,726.32
|
| Rate for Payer: United Healthcare All Payer |
$7,999.13
|
|
|
DELTA CER HEAD 12/14 28MM +5
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 12/14 28MM +5
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 12/14 28MM +8.5
|
Facility
|
OP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem Medicaid |
$3,181.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Humana KY Medicaid |
$3,181.16
|
| Rate for Payer: Kentucky WC Medicaid |
$3,213.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,244.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 12/14 28MM +8.5
|
Facility
|
IP
|
$9,250.26
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,775.08 |
| Max. Negotiated Rate |
$8,880.25 |
| Rate for Payer: Aetna Commercial |
$7,122.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,215.20
|
| Rate for Payer: Cash Price |
$4,625.13
|
| Rate for Payer: Cigna Commercial |
$7,677.72
|
| Rate for Payer: First Health Commercial |
$8,787.75
|
| Rate for Payer: Humana Commercial |
$7,862.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,585.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,826.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,775.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,140.23
|
| Rate for Payer: Ohio Health Group HMO |
$6,937.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,400.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,047.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,382.68
|
| Rate for Payer: PHCS Commercial |
$8,880.25
|
| Rate for Payer: United Healthcare All Payer |
$8,140.23
|
|
|
DELTA CER HEAD 12/14 32MM +1
|
Facility
|
IP
|
$9,556.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,867.06 |
| Max. Negotiated Rate |
$9,174.59 |
| Rate for Payer: Aetna Commercial |
$7,358.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,454.35
|
| Rate for Payer: Cash Price |
$4,778.43
|
| Rate for Payer: Cigna Commercial |
$7,932.19
|
| Rate for Payer: First Health Commercial |
$9,079.02
|
| Rate for Payer: Humana Commercial |
$8,123.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,836.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,052.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,867.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,410.04
|
| Rate for Payer: Ohio Health Group HMO |
$7,167.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,645.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,314.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,594.23
|
| Rate for Payer: PHCS Commercial |
$9,174.59
|
| Rate for Payer: United Healthcare All Payer |
$8,410.04
|
|
|
DELTA CER HEAD 12/14 32MM +1
|
Facility
|
OP
|
$9,556.86
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,867.06 |
| Max. Negotiated Rate |
$9,174.59 |
| Rate for Payer: Aetna Commercial |
$7,358.78
|
| Rate for Payer: Anthem Medicaid |
$3,286.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,454.35
|
| Rate for Payer: Cash Price |
$4,778.43
|
| Rate for Payer: Cigna Commercial |
$7,932.19
|
| Rate for Payer: First Health Commercial |
$9,079.02
|
| Rate for Payer: Humana Commercial |
$8,123.33
|
| Rate for Payer: Humana KY Medicaid |
$3,286.60
|
| Rate for Payer: Kentucky WC Medicaid |
$3,320.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,836.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,052.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,867.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,352.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,410.04
|
| Rate for Payer: Ohio Health Group HMO |
$7,167.65
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,645.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,314.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,594.23
|
| Rate for Payer: PHCS Commercial |
$9,174.59
|
| Rate for Payer: United Healthcare All Payer |
$8,410.04
|
|
|
DELTA CER HEAD 12/14 32MM +1.0
|
Facility
|
OP
|
$11,147.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,344.26 |
| Max. Negotiated Rate |
$10,701.65 |
| Rate for Payer: Aetna Commercial |
$8,583.61
|
| Rate for Payer: Anthem Medicaid |
$3,833.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,695.09
|
| Rate for Payer: Cash Price |
$5,573.77
|
| Rate for Payer: Cigna Commercial |
$9,252.47
|
| Rate for Payer: First Health Commercial |
$10,590.17
|
| Rate for Payer: Humana Commercial |
$9,475.42
|
| Rate for Payer: Humana KY Medicaid |
$3,833.64
|
| Rate for Payer: Kentucky WC Medicaid |
$3,872.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,140.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,226.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,344.26
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,910.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,809.84
|
| Rate for Payer: Ohio Health Group HMO |
$8,360.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,918.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,698.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,691.81
|
| Rate for Payer: PHCS Commercial |
$10,701.65
|
| Rate for Payer: United Healthcare All Payer |
$9,809.84
|
|
