|
LINER ALTRX NEUTRAL 40*66
|
Facility
|
OP
|
$20,003.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,001.12 |
| Max. Negotiated Rate |
$19,203.60 |
| Rate for Payer: Aetna Commercial |
$15,402.89
|
| Rate for Payer: Anthem Medicaid |
$6,879.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,602.92
|
| Rate for Payer: Cash Price |
$10,001.88
|
| Rate for Payer: Cigna Commercial |
$16,603.11
|
| Rate for Payer: First Health Commercial |
$19,003.56
|
| Rate for Payer: Humana Commercial |
$17,003.19
|
| Rate for Payer: Humana KY Medicaid |
$6,879.29
|
| Rate for Payer: Kentucky WC Medicaid |
$6,949.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,403.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,762.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,001.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,017.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,603.30
|
| Rate for Payer: Ohio Health Group HMO |
$15,002.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,003.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,403.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,802.59
|
| Rate for Payer: PHCS Commercial |
$19,203.60
|
| Rate for Payer: United Healthcare All Payer |
$17,603.30
|
|
|
LINER ALTRX NEUTRAL 40*66
|
Facility
|
IP
|
$20,003.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,001.12 |
| Max. Negotiated Rate |
$19,203.60 |
| Rate for Payer: Aetna Commercial |
$15,402.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,602.92
|
| Rate for Payer: Cash Price |
$10,001.88
|
| Rate for Payer: Cigna Commercial |
$16,603.11
|
| Rate for Payer: First Health Commercial |
$19,003.56
|
| Rate for Payer: Humana Commercial |
$17,003.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,403.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,762.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,001.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,603.30
|
| Rate for Payer: Ohio Health Group HMO |
$15,002.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$16,003.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$17,403.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,802.59
|
| Rate for Payer: PHCS Commercial |
$19,203.60
|
| Rate for Payer: United Healthcare All Payer |
$17,603.30
|
|
|
LINER ALUM CER 28ID 46-48 OD
|
Facility
|
IP
|
$9,223.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,767.08 |
| Max. Negotiated Rate |
$8,854.67 |
| Rate for Payer: Aetna Commercial |
$7,102.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,194.42
|
| Rate for Payer: Cash Price |
$4,611.81
|
| Rate for Payer: Cigna Commercial |
$7,655.60
|
| Rate for Payer: First Health Commercial |
$8,762.43
|
| Rate for Payer: Humana Commercial |
$7,840.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,563.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,807.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,767.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,116.78
|
| Rate for Payer: Ohio Health Group HMO |
$6,917.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,378.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,024.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,364.29
|
| Rate for Payer: PHCS Commercial |
$8,854.67
|
| Rate for Payer: United Healthcare All Payer |
$8,116.78
|
|
|
LINER ALUM CER 28ID 46-48 OD
|
Facility
|
OP
|
$9,223.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,767.08 |
| Max. Negotiated Rate |
$8,854.67 |
| Rate for Payer: Aetna Commercial |
$7,102.18
|
| Rate for Payer: Anthem Medicaid |
$3,172.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,194.42
|
| Rate for Payer: Cash Price |
$4,611.81
|
| Rate for Payer: Cigna Commercial |
$7,655.60
|
| Rate for Payer: First Health Commercial |
$8,762.43
|
| Rate for Payer: Humana Commercial |
$7,840.07
|
| Rate for Payer: Humana KY Medicaid |
$3,172.00
|
| Rate for Payer: Kentucky WC Medicaid |
$3,204.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,563.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,807.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,767.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,235.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,116.78
|
| Rate for Payer: Ohio Health Group HMO |
$6,917.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,378.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,024.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,364.29
|
| Rate for Payer: PHCS Commercial |
$8,854.67
|
| Rate for Payer: United Healthcare All Payer |
$8,116.78
|
|
|
LINER ALUM CER 32ID 50-54 OD
|
Facility
|
IP
|
$7,393.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,217.94 |
| Max. Negotiated Rate |
$7,097.41 |
| Rate for Payer: Aetna Commercial |
$5,692.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,766.65
|
| Rate for Payer: Cash Price |
$3,696.57
|
| Rate for Payer: Cigna Commercial |
$6,136.31
|
| Rate for Payer: First Health Commercial |
$7,023.48
|
| Rate for Payer: Humana Commercial |
$6,284.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,062.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,456.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,217.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,505.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,544.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,914.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,432.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,101.27
|
| Rate for Payer: PHCS Commercial |
$7,097.41
|
| Rate for Payer: United Healthcare All Payer |
$6,505.96
|
|
|
LINER ALUM CER 32ID 50-54 OD
|
Facility
|
OP
|
$7,393.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,217.94 |
| Max. Negotiated Rate |
$7,097.41 |
| Rate for Payer: Aetna Commercial |
$5,692.72
|
| Rate for Payer: Anthem Medicaid |
$2,542.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,766.65
|
| Rate for Payer: Cash Price |
$3,696.57
|
| Rate for Payer: Cigna Commercial |
$6,136.31
|
| Rate for Payer: First Health Commercial |
$7,023.48
|
| Rate for Payer: Humana Commercial |
$6,284.17
|
| Rate for Payer: Humana KY Medicaid |
$2,542.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,568.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,062.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,456.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,217.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,505.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,544.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,914.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,432.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,101.27
|
| Rate for Payer: PHCS Commercial |
$7,097.41
|
| Rate for Payer: United Healthcare All Payer |
$6,505.96
|
|
|
LINER ALUM CER 32ID 56-66 OD
|
Facility
|
IP
|
$7,393.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,217.94 |
| Max. Negotiated Rate |
$7,097.41 |
| Rate for Payer: Aetna Commercial |
$5,692.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,766.65
|
| Rate for Payer: Cash Price |
$3,696.57
|
| Rate for Payer: Cigna Commercial |
$6,136.31
|
| Rate for Payer: First Health Commercial |
$7,023.48
|
| Rate for Payer: Humana Commercial |
$6,284.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,062.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,456.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,217.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,505.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,544.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,914.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,432.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,101.27
|
| Rate for Payer: PHCS Commercial |
$7,097.41
|
| Rate for Payer: United Healthcare All Payer |
$6,505.96
|
|
|
LINER ALUM CER 32ID 56-66 OD
|
Facility
|
OP
|
$7,393.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,217.94 |
| Max. Negotiated Rate |
$7,097.41 |
| Rate for Payer: Aetna Commercial |
$5,692.72
|
| Rate for Payer: Anthem Medicaid |
$2,542.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,766.65
|
| Rate for Payer: Cash Price |
$3,696.57
|
| Rate for Payer: Cigna Commercial |
$6,136.31
|
| Rate for Payer: First Health Commercial |
$7,023.48
|
| Rate for Payer: Humana Commercial |
$6,284.17
|
| Rate for Payer: Humana KY Medicaid |
$2,542.50
|
| Rate for Payer: Kentucky WC Medicaid |
$2,568.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,062.37
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,456.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,217.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,593.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,505.96
|
| Rate for Payer: Ohio Health Group HMO |
$5,544.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,914.51
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,432.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,101.27
|
| Rate for Payer: PHCS Commercial |
$7,097.41
|
| Rate for Payer: United Healthcare All Payer |
$6,505.96
|
|
|
LINER ALUM CER SAM 32 50-54
|
Facility
|
OP
|
$2,060.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.01 |
| Max. Negotiated Rate |
$1,977.64 |
| Rate for Payer: Aetna Commercial |
$1,586.23
|
| Rate for Payer: Anthem Medicaid |
$708.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.83
|
| Rate for Payer: Cash Price |
$1,030.02
|
| Rate for Payer: Cigna Commercial |
$1,709.83
|
| Rate for Payer: First Health Commercial |
$1,957.04
|
| Rate for Payer: Humana Commercial |
$1,751.03
|
| Rate for Payer: Humana KY Medicaid |
$708.45
|
| Rate for Payer: Kentucky WC Medicaid |
$715.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$722.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.43
|
| Rate for Payer: PHCS Commercial |
$1,977.64
|
| Rate for Payer: United Healthcare All Payer |
$1,812.84
|
|
|
LINER ALUM CER SAM 32 50-54
|
Facility
|
IP
|
$2,060.04
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$618.01 |
| Max. Negotiated Rate |
$1,977.64 |
| Rate for Payer: Aetna Commercial |
$1,586.23
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,606.83
|
| Rate for Payer: Cash Price |
$1,030.02
|
| Rate for Payer: Cigna Commercial |
$1,709.83
|
| Rate for Payer: First Health Commercial |
$1,957.04
|
| Rate for Payer: Humana Commercial |
$1,751.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,689.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,520.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$618.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,812.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,545.03
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,648.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,792.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,421.43
|
| Rate for Payer: PHCS Commercial |
$1,977.64
|
| Rate for Payer: United Healthcare All Payer |
$1,812.84
|
|
|
LINER ANTEV XLPE 20^ +4 32X48
|
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
|
|
|
LINER ANTEV XLPE 20^ +4 32X48
|
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
|
|
|
LINER ANTEV XLPE 20^ +4 32X50
|
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
|
|
|
LINER ANTEV XLPE 20^ +4 32X50
|
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
|
|
|
LINER ANTEV XLPE 20^ +4 36X52
|
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
|
|
|
LINER ANTEV XLPE 20^ +4 36X52
|
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
|
|
|
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 |
$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
|
|
|
LINER ANTEV XLPE 20^ +4 36X54
|
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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
