|
LINER ANTEV XLPE 20^ +4 36X54
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X56
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X56
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X58
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X58
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X60
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X60
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X62
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X62
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X64
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEV XLPE 20^ +4 36X64
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEVXLPE 20^+4 36X66/70
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEVXLPE 20^+4 36X66/70
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEVXLPE 20^+4 36X72/74
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTEVXLPE 20^+4 36X72/74
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$650.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$650.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,550.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
LINER ANTE XLPE CMT 32X50MM
|
Facility
|
IP
|
$7,775.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.77 |
| Max. Negotiated Rate |
$7,464.12 |
| Rate for Payer: Aetna Commercial |
$5,986.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,064.60
|
| Rate for Payer: Cash Price |
$3,887.57
|
| Rate for Payer: Cigna Commercial |
$6,453.36
|
| Rate for Payer: First Health Commercial |
$7,386.37
|
| Rate for Payer: Humana Commercial |
$6,608.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,375.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,738.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,332.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,842.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,831.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,555.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.29
|
| Rate for Payer: PHCS Commercial |
$7,464.12
|
| Rate for Payer: United Healthcare All Payer |
$6,842.11
|
|
|
LINER ANTE XLPE CMT 32X50MM
|
Facility
|
OP
|
$7,775.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.77 |
| Max. Negotiated Rate |
$7,464.12 |
| Rate for Payer: Aetna Commercial |
$5,986.85
|
| Rate for Payer: Anthem Medicaid |
$2,673.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,064.60
|
| Rate for Payer: Cash Price |
$3,887.57
|
| Rate for Payer: Cigna Commercial |
$6,453.36
|
| Rate for Payer: First Health Commercial |
$7,386.37
|
| Rate for Payer: Humana Commercial |
$6,608.86
|
| Rate for Payer: Humana KY Medicaid |
$2,673.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,701.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,375.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,738.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,332.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,727.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,842.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,831.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,555.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.29
|
| Rate for Payer: PHCS Commercial |
$7,464.12
|
| Rate for Payer: United Healthcare All Payer |
$6,842.11
|
|
|
LINER ANTE XLPE CMT 36X54MM
|
Facility
|
IP
|
$7,775.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.77 |
| Max. Negotiated Rate |
$7,464.12 |
| Rate for Payer: Aetna Commercial |
$5,986.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,064.60
|
| Rate for Payer: Cash Price |
$3,887.57
|
| Rate for Payer: Cigna Commercial |
$6,453.36
|
| Rate for Payer: First Health Commercial |
$7,386.37
|
| Rate for Payer: Humana Commercial |
$6,608.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,375.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,738.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,332.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,842.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,831.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,555.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.29
|
| Rate for Payer: PHCS Commercial |
$7,464.12
|
| Rate for Payer: United Healthcare All Payer |
$6,842.11
|
|
|
LINER ANTE XLPE CMT 36X54MM
|
Facility
|
OP
|
$7,775.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.77 |
| Max. Negotiated Rate |
$7,464.12 |
| Rate for Payer: Aetna Commercial |
$5,986.85
|
| Rate for Payer: Anthem Medicaid |
$2,673.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,064.60
|
| Rate for Payer: Cash Price |
$3,887.57
|
| Rate for Payer: Cigna Commercial |
$6,453.36
|
| Rate for Payer: First Health Commercial |
$7,386.37
|
| Rate for Payer: Humana Commercial |
$6,608.86
|
| Rate for Payer: Humana KY Medicaid |
$2,673.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,701.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,375.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,738.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,332.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,727.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,842.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,831.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,555.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.29
|
| Rate for Payer: PHCS Commercial |
$7,464.12
|
| Rate for Payer: United Healthcare All Payer |
$6,842.11
|
|
|
LINER ANTE XLPE CMT 40X58MM
|
Facility
|
IP
|
$7,775.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.77 |
| Max. Negotiated Rate |
$7,464.12 |
| Rate for Payer: Aetna Commercial |
$5,986.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,064.60
|
| Rate for Payer: Cash Price |
$3,887.57
|
| Rate for Payer: Cigna Commercial |
$6,453.36
|
| Rate for Payer: First Health Commercial |
$7,386.37
|
| Rate for Payer: Humana Commercial |
$6,608.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,375.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,738.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,332.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,842.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,831.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,555.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.29
|
| Rate for Payer: PHCS Commercial |
$7,464.12
|
| Rate for Payer: United Healthcare All Payer |
$6,842.11
|
|
|
LINER ANTE XLPE CMT 40X58MM
|
Facility
|
OP
|
$7,775.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,010.77 |
| Max. Negotiated Rate |
$7,464.12 |
| Rate for Payer: Aetna Commercial |
$5,986.85
|
| Rate for Payer: Anthem Medicaid |
$2,673.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,064.60
|
| Rate for Payer: Cash Price |
$3,887.57
|
| Rate for Payer: Cigna Commercial |
$6,453.36
|
| Rate for Payer: First Health Commercial |
$7,386.37
|
| Rate for Payer: Humana Commercial |
$6,608.86
|
| Rate for Payer: Humana KY Medicaid |
$2,673.87
|
| Rate for Payer: Kentucky WC Medicaid |
$2,701.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,375.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,738.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,332.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,727.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,842.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,831.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,555.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,010.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,410.29
|
| Rate for Payer: PHCS Commercial |
$7,464.12
|
| Rate for Payer: United Healthcare All Payer |
$6,842.11
|
|
|
LINER ARCOM RNGLOC 10^ 28*22
|
Facility
|
OP
|
$4,720.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.60 |
| Max. Negotiated Rate |
$4,531.20 |
| Rate for Payer: Aetna Commercial |
$3,634.40
|
| Rate for Payer: Anthem Medicaid |
$1,623.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,681.60
|
| Rate for Payer: Cash Price |
$2,360.00
|
| Rate for Payer: Cigna Commercial |
$3,917.60
|
| Rate for Payer: First Health Commercial |
$4,484.00
|
| Rate for Payer: Humana Commercial |
$4,012.00
|
| Rate for Payer: Humana KY Medicaid |
$1,623.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,639.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,870.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,483.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,655.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,153.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$613.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.20
|
| Rate for Payer: PHCS Commercial |
$4,531.20
|
| Rate for Payer: United Healthcare All Payer |
$4,153.60
|
|
|
LINER ARCOM RNGLOC 10^ 28*22
|
Facility
|
IP
|
$4,720.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.60 |
| Max. Negotiated Rate |
$4,531.20 |
| Rate for Payer: Aetna Commercial |
$3,634.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,681.60
|
| Rate for Payer: Cash Price |
$2,360.00
|
| Rate for Payer: Cigna Commercial |
$3,917.60
|
| Rate for Payer: First Health Commercial |
$4,484.00
|
| Rate for Payer: Humana Commercial |
$4,012.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,870.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,483.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,153.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$613.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.20
|
| Rate for Payer: PHCS Commercial |
$4,531.20
|
| Rate for Payer: United Healthcare All Payer |
$4,153.60
|
|
|
LINER ARCOM RNGLOC 10^ 28*23
|
Facility
|
IP
|
$4,720.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.60 |
| Max. Negotiated Rate |
$4,531.20 |
| Rate for Payer: Aetna Commercial |
$3,634.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,681.60
|
| Rate for Payer: Cash Price |
$2,360.00
|
| Rate for Payer: Cigna Commercial |
$3,917.60
|
| Rate for Payer: First Health Commercial |
$4,484.00
|
| Rate for Payer: Humana Commercial |
$4,012.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,870.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,483.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,153.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$613.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.20
|
| Rate for Payer: PHCS Commercial |
$4,531.20
|
| Rate for Payer: United Healthcare All Payer |
$4,153.60
|
|
|
LINER ARCOM RNGLOC 10^ 28*23
|
Facility
|
OP
|
$4,720.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$613.60 |
| Max. Negotiated Rate |
$4,531.20 |
| Rate for Payer: Aetna Commercial |
$3,634.40
|
| Rate for Payer: Anthem Medicaid |
$1,623.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,681.60
|
| Rate for Payer: Cash Price |
$2,360.00
|
| Rate for Payer: Cigna Commercial |
$3,917.60
|
| Rate for Payer: First Health Commercial |
$4,484.00
|
| Rate for Payer: Humana Commercial |
$4,012.00
|
| Rate for Payer: Humana KY Medicaid |
$1,623.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,639.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,870.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,483.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,655.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,153.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$944.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$613.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,463.20
|
| Rate for Payer: PHCS Commercial |
$4,531.20
|
| Rate for Payer: United Healthcare All Payer |
$4,153.60
|
|
