|
EVERCROSS .035 OTW PTA 8*20*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*20*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*40*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*40*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*60*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*60*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*80*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 8*80*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*20*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*20*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*40*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*40*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*60*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*60*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*80*80
|
Facility
|
OP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem Medicaid |
$530.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Humana KY Medicaid |
$530.29
|
| Rate for Payer: Kentucky WC Medicaid |
$535.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$540.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 OTW PTA 9*80*80
|
Facility
|
IP
|
$1,542.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$462.60 |
| Max. Negotiated Rate |
$1,480.32 |
| Rate for Payer: Aetna Commercial |
$1,187.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,202.76
|
| Rate for Payer: Cash Price |
$771.00
|
| Rate for Payer: Cigna Commercial |
$1,279.86
|
| Rate for Payer: First Health Commercial |
$1,464.90
|
| Rate for Payer: Humana Commercial |
$1,310.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,264.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,138.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$462.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,356.96
|
| Rate for Payer: Ohio Health Group HMO |
$1,156.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,233.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,341.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.98
|
| Rate for Payer: PHCS Commercial |
$1,480.32
|
| Rate for Payer: United Healthcare All Payer |
$1,356.96
|
|
|
EVERCROSS .035 PTA OTW 5*60*80
|
Facility
|
IP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERCROSS .035 PTA OTW 5*60*80
|
Facility
|
OP
|
$1,680.00
|
|
|
Service Code
|
HCPCS C1725
|
| Hospital Charge Code |
27000009
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$504.00 |
| Max. Negotiated Rate |
$1,612.80 |
| Rate for Payer: Aetna Commercial |
$1,293.60
|
| Rate for Payer: Anthem Medicaid |
$577.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,310.40
|
| Rate for Payer: Cash Price |
$840.00
|
| Rate for Payer: Cigna Commercial |
$1,394.40
|
| Rate for Payer: First Health Commercial |
$1,596.00
|
| Rate for Payer: Humana Commercial |
$1,428.00
|
| Rate for Payer: Humana KY Medicaid |
$577.75
|
| Rate for Payer: Kentucky WC Medicaid |
$583.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,377.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,239.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$504.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$589.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,478.40
|
| Rate for Payer: Ohio Health Group HMO |
$1,260.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,344.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,159.20
|
| Rate for Payer: PHCS Commercial |
$1,612.80
|
| Rate for Payer: United Healthcare All Payer |
$1,478.40
|
|
|
EVERFLEX ENTRUSE 5F 6*100*150
|
Facility
|
IP
|
$13,042.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
EVERFLEX ENTRUSE 5F 6*100*150
|
Facility
|
OP
|
$13,042.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,912.60 |
| Max. Negotiated Rate |
$12,520.32 |
| Rate for Payer: Aetna Commercial |
$10,042.34
|
| Rate for Payer: Anthem Medicaid |
$4,485.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,172.76
|
| Rate for Payer: Cash Price |
$6,521.00
|
| Rate for Payer: Cigna Commercial |
$10,824.86
|
| Rate for Payer: First Health Commercial |
$12,389.90
|
| Rate for Payer: Humana Commercial |
$11,085.70
|
| Rate for Payer: Humana KY Medicaid |
$4,485.14
|
| Rate for Payer: Kentucky WC Medicaid |
$4,530.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,694.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,625.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,912.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,575.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,476.96
|
| Rate for Payer: Ohio Health Group HMO |
$9,781.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,433.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,346.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,998.98
|
| Rate for Payer: PHCS Commercial |
$12,520.32
|
| Rate for Payer: United Healthcare All Payer |
$11,476.96
|
|
|
EVERFLEX ENTRUST 5F 6*120*150
|
Facility
|
IP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
EVERFLEX ENTRUST 5F 6*120*150
|
Facility
|
OP
|
$7,015.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,104.50 |
| Max. Negotiated Rate |
$6,734.40 |
| Rate for Payer: Aetna Commercial |
$5,401.55
|
| Rate for Payer: Anthem Medicaid |
$2,412.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,471.70
|
| Rate for Payer: Cash Price |
$3,507.50
|
| Rate for Payer: Cigna Commercial |
$5,822.45
|
| Rate for Payer: First Health Commercial |
$6,664.25
|
| Rate for Payer: Humana Commercial |
$5,962.75
|
| Rate for Payer: Humana KY Medicaid |
$2,412.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,437.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,752.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,177.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,104.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,460.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,173.20
|
| Rate for Payer: Ohio Health Group HMO |
$5,261.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,612.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,103.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,840.35
|
| Rate for Payer: PHCS Commercial |
$6,734.40
|
| Rate for Payer: United Healthcare All Payer |
$6,173.20
|
|
|
EVERFLEX ENTRUST 5F 6*150*150
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
EVERFLEX ENTRUST 5F 6*150*150
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
EVERFLEX ENTRUST 5F 6*20*150
|
Facility
|
IP
|
$4,250.00
|
|
|
Service Code
|
HCPCS C1874
|
| Hospital Charge Code |
27000125
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,275.00 |
| Max. Negotiated Rate |
$4,080.00 |
| Rate for Payer: Aetna Commercial |
$3,272.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,315.00
|
| Rate for Payer: Cash Price |
$2,125.00
|
| Rate for Payer: Cigna Commercial |
$3,527.50
|
| Rate for Payer: First Health Commercial |
$4,037.50
|
| Rate for Payer: Humana Commercial |
$3,612.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,485.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,136.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,275.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,740.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,187.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,697.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,932.50
|
| Rate for Payer: PHCS Commercial |
$4,080.00
|
| Rate for Payer: United Healthcare All Payer |
$3,740.00
|
|
