|
EVOLUTN ADAP INS SZ4/1 R 20MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/1 R 20MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 10MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 10MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 12MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 12MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 14MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 14MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 17MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 17MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 20MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 L 20MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 10MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 10MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 12MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 12MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 14MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 14MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 17MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 17MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ4/2 R 20MM
|
Facility
|
OP
|
$6,851.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.70 |
| Max. Negotiated Rate |
$6,577.44 |
| Rate for Payer: Aetna Commercial |
$5,275.66
|
| Rate for Payer: Anthem Medicaid |
$2,356.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,344.17
|
| Rate for Payer: Cash Price |
$3,425.75
|
| Rate for Payer: Cigna Commercial |
$5,686.74
|
| Rate for Payer: First Health Commercial |
$6,508.92
|
| Rate for Payer: Humana Commercial |
$5,823.78
|
| Rate for Payer: Humana KY Medicaid |
$2,356.23
|
| Rate for Payer: Kentucky WC Medicaid |
$2,380.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,618.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,056.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,403.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,029.32
|
| Rate for Payer: Ohio Health Group HMO |
$5,138.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,123.96
|
| Rate for Payer: PHCS Commercial |
$6,577.44
|
| Rate for Payer: United Healthcare All Payer |
$6,029.32
|
|
|
EVOLUTN ADAP INS SZ4/2 R 20MM
|
Facility
|
IP
|
$6,851.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$890.70 |
| Max. Negotiated Rate |
$6,577.44 |
| Rate for Payer: Aetna Commercial |
$5,275.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,344.17
|
| Rate for Payer: Cash Price |
$3,425.75
|
| Rate for Payer: Cigna Commercial |
$5,686.74
|
| Rate for Payer: First Health Commercial |
$6,508.92
|
| Rate for Payer: Humana Commercial |
$5,823.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,618.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,056.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,055.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,029.32
|
| Rate for Payer: Ohio Health Group HMO |
$5,138.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,370.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$890.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,123.96
|
| Rate for Payer: PHCS Commercial |
$6,577.44
|
| Rate for Payer: United Healthcare All Payer |
$6,029.32
|
|
|
EVOLUTN ADAP INS SZ5/2 L 10MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ5/2 L 10MM
|
Facility
|
OP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem Medicaid |
$2,343.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Humana KY Medicaid |
$2,343.68
|
| Rate for Payer: Kentucky WC Medicaid |
$2,367.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,390.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
|
EVOLUTN ADAP INS SZ5/2 L 12MM
|
Facility
|
IP
|
$6,815.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$885.95 |
| Max. Negotiated Rate |
$6,542.40 |
| Rate for Payer: Aetna Commercial |
$5,247.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,315.70
|
| Rate for Payer: Cash Price |
$3,407.50
|
| Rate for Payer: Cigna Commercial |
$5,656.45
|
| Rate for Payer: First Health Commercial |
$6,474.25
|
| Rate for Payer: Humana Commercial |
$5,792.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,588.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,029.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,044.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,997.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,111.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,363.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$885.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,112.65
|
| Rate for Payer: PHCS Commercial |
$6,542.40
|
| Rate for Payer: United Healthcare All Payer |
$5,997.20
|
|
