|
GII C/R DP TIB SZ 7*11MM R
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 7*13MM L
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 7*13MM L
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 7*9MM L
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 7*9MM L
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 8*11MM L
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 8*11MM L
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 8*11MM R
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII C/R DP TIB SZ 8*11MM R
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
GII CR HA POROUS FEM SZ 3 LT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 3 LT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 3 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 3 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 4 LT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 4 LT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 4 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 4 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 5 LT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 5 LT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 5 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 5 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 6 LT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 6 LT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 6 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII CR HA POROUS FEM SZ 6 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
