|
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 |
$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 36X64
|
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 36X64
|
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 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 |
$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 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 |
$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 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 |
$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 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 |
$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 ANTE XLPE CMT 32X50MM
|
Facility
|
IP
|
$7,975.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.54 |
| Max. Negotiated Rate |
$7,656.12 |
| Rate for Payer: Aetna Commercial |
$6,140.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.60
|
| Rate for Payer: Cash Price |
$3,987.57
|
| Rate for Payer: Cigna Commercial |
$6,619.36
|
| Rate for Payer: First Health Commercial |
$7,576.37
|
| Rate for Payer: Humana Commercial |
$6,778.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.84
|
| Rate for Payer: PHCS Commercial |
$7,656.12
|
| Rate for Payer: United Healthcare All Payer |
$7,018.11
|
|
|
LINER ANTE XLPE CMT 32X50MM
|
Facility
|
OP
|
$7,975.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.54 |
| Max. Negotiated Rate |
$7,656.12 |
| Rate for Payer: Aetna Commercial |
$6,140.85
|
| Rate for Payer: Anthem Medicaid |
$2,742.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.60
|
| Rate for Payer: Cash Price |
$3,987.57
|
| Rate for Payer: Cigna Commercial |
$6,619.36
|
| Rate for Payer: First Health Commercial |
$7,576.37
|
| Rate for Payer: Humana Commercial |
$6,778.86
|
| Rate for Payer: Humana KY Medicaid |
$2,742.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,770.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,797.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.84
|
| Rate for Payer: PHCS Commercial |
$7,656.12
|
| Rate for Payer: United Healthcare All Payer |
$7,018.11
|
|
|
LINER ANTE XLPE CMT 36X54MM
|
Facility
|
IP
|
$7,975.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.54 |
| Max. Negotiated Rate |
$7,656.12 |
| Rate for Payer: Aetna Commercial |
$6,140.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.60
|
| Rate for Payer: Cash Price |
$3,987.57
|
| Rate for Payer: Cigna Commercial |
$6,619.36
|
| Rate for Payer: First Health Commercial |
$7,576.37
|
| Rate for Payer: Humana Commercial |
$6,778.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.84
|
| Rate for Payer: PHCS Commercial |
$7,656.12
|
| Rate for Payer: United Healthcare All Payer |
$7,018.11
|
|
|
LINER ANTE XLPE CMT 36X54MM
|
Facility
|
OP
|
$7,975.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.54 |
| Max. Negotiated Rate |
$7,656.12 |
| Rate for Payer: Aetna Commercial |
$6,140.85
|
| Rate for Payer: Anthem Medicaid |
$2,742.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.60
|
| Rate for Payer: Cash Price |
$3,987.57
|
| Rate for Payer: Cigna Commercial |
$6,619.36
|
| Rate for Payer: First Health Commercial |
$7,576.37
|
| Rate for Payer: Humana Commercial |
$6,778.86
|
| Rate for Payer: Humana KY Medicaid |
$2,742.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,770.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,797.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.84
|
| Rate for Payer: PHCS Commercial |
$7,656.12
|
| Rate for Payer: United Healthcare All Payer |
$7,018.11
|
|
|
LINER ANTE XLPE CMT 40X58MM
|
Facility
|
OP
|
$7,975.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.54 |
| Max. Negotiated Rate |
$7,656.12 |
| Rate for Payer: Aetna Commercial |
$6,140.85
|
| Rate for Payer: Anthem Medicaid |
$2,742.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.60
|
| Rate for Payer: Cash Price |
$3,987.57
|
| Rate for Payer: Cigna Commercial |
$6,619.36
|
| Rate for Payer: First Health Commercial |
$7,576.37
|
| Rate for Payer: Humana Commercial |
$6,778.86
|
| Rate for Payer: Humana KY Medicaid |
$2,742.65
|
| Rate for Payer: Kentucky WC Medicaid |
$2,770.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,797.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.84
|
| Rate for Payer: PHCS Commercial |
$7,656.12
|
| Rate for Payer: United Healthcare All Payer |
$7,018.11
|
|
|
LINER ANTE XLPE CMT 40X58MM
|
Facility
|
IP
|
$7,975.13
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,392.54 |
| Max. Negotiated Rate |
$7,656.12 |
| Rate for Payer: Aetna Commercial |
$6,140.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,220.60
|
| Rate for Payer: Cash Price |
$3,987.57
|
| Rate for Payer: Cigna Commercial |
$6,619.36
|
| Rate for Payer: First Health Commercial |
$7,576.37
|
| Rate for Payer: Humana Commercial |
$6,778.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,539.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,885.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,392.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,018.11
|
| Rate for Payer: Ohio Health Group HMO |
$5,981.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,380.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,938.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,502.84
|
| Rate for Payer: PHCS Commercial |
$7,656.12
|
| Rate for Payer: United Healthcare All Payer |
$7,018.11
|
|
|
LINER ARCOM RNGLOC 10^ 28*22
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem Medicaid |
$1,616.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Humana KY Medicaid |
$1,616.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 28*22
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 28*23
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 28*23
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem Medicaid |
$1,616.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Humana KY Medicaid |
$1,616.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*23
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem Medicaid |
$1,616.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Humana KY Medicaid |
$1,616.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*23
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*24
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem Medicaid |
$1,616.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Humana KY Medicaid |
$1,616.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*24
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*25
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*25
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem Medicaid |
$1,616.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Humana KY Medicaid |
$1,616.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*26
|
Facility
|
IP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
|
LINER ARCOM RNGLOC 10^ 32*26
|
Facility
|
OP
|
$4,700.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,410.00 |
| Max. Negotiated Rate |
$4,512.00 |
| Rate for Payer: Aetna Commercial |
$3,619.00
|
| Rate for Payer: Anthem Medicaid |
$1,616.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,666.00
|
| Rate for Payer: Cash Price |
$2,350.00
|
| Rate for Payer: Cigna Commercial |
$3,901.00
|
| Rate for Payer: First Health Commercial |
$4,465.00
|
| Rate for Payer: Humana Commercial |
$3,995.00
|
| Rate for Payer: Humana KY Medicaid |
$1,616.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,632.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,854.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,468.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,410.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,648.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,136.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,525.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,760.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,089.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,243.00
|
| Rate for Payer: PHCS Commercial |
$4,512.00
|
| Rate for Payer: United Healthcare All Payer |
$4,136.00
|
|
