|
LINER R3 20^ XLPE ACE 44*62
|
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 R3 20^ XLPE ACE 44*64
|
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 R3 20^ XLPE ACE 44*64
|
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 R3 20^ XLPE ACE 44*66-70
|
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 R3 20^ XLPE ACE 44*66-70
|
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 R3 20^ XLPE ACE 44*72-74
|
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 R3 20^ XLPE ACE 44*72-74
|
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 R3 20^ XLPE ACE 44*76-80
|
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 R3 20^ XLPE ACE 44*76-80
|
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 R3 20^ XLPE ACET36*72-74
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^ XLPE ACET36*72-74
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20 XLPE ACET 40*56
|
Facility
|
OP
|
$8,612.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,119.63 |
| Max. Negotiated Rate |
$8,268.02 |
| Rate for Payer: Aetna Commercial |
$6,631.64
|
| Rate for Payer: Anthem Medicaid |
$2,961.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,717.77
|
| Rate for Payer: Cash Price |
$4,306.26
|
| Rate for Payer: Cigna Commercial |
$7,148.39
|
| Rate for Payer: First Health Commercial |
$8,181.89
|
| Rate for Payer: Humana Commercial |
$7,320.64
|
| Rate for Payer: Humana KY Medicaid |
$2,961.85
|
| Rate for Payer: Kentucky WC Medicaid |
$2,991.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,062.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,356.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,021.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,579.02
|
| Rate for Payer: Ohio Health Group HMO |
$6,459.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,722.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,119.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,669.88
|
| Rate for Payer: PHCS Commercial |
$8,268.02
|
| Rate for Payer: United Healthcare All Payer |
$7,579.02
|
|
|
LINER R3 20 XLPE ACET 40*56
|
Facility
|
IP
|
$8,612.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,119.63 |
| Max. Negotiated Rate |
$8,268.02 |
| Rate for Payer: Aetna Commercial |
$6,631.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,717.77
|
| Rate for Payer: Cash Price |
$4,306.26
|
| Rate for Payer: Cigna Commercial |
$7,148.39
|
| Rate for Payer: First Health Commercial |
$8,181.89
|
| Rate for Payer: Humana Commercial |
$7,320.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,062.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,356.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,583.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,579.02
|
| Rate for Payer: Ohio Health Group HMO |
$6,459.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,722.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,119.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,669.88
|
| Rate for Payer: PHCS Commercial |
$8,268.02
|
| Rate for Payer: United Healthcare All Payer |
$7,579.02
|
|
|
LINER R3 20 XLPE ACET 40*58
|
Facility
|
IP
|
$11,795.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LINER R3 20 XLPE ACET 40*58
|
Facility
|
OP
|
$11,795.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem Medicaid |
$4,056.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Humana KY Medicaid |
$4,056.43
|
| Rate for Payer: Kentucky WC Medicaid |
$4,097.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,137.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LINER R3 20 XLPE ACET 40*60
|
Facility
|
OP
|
$11,795.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem Medicaid |
$4,056.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Humana KY Medicaid |
$4,056.43
|
| Rate for Payer: Kentucky WC Medicaid |
$4,097.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,137.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LINER R3 20 XLPE ACET 40*60
|
Facility
|
IP
|
$11,795.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LINER R3 20 XLPE ACET 40*62
|
Facility
|
IP
|
$11,795.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LINER R3 20 XLPE ACET 40*62
|
Facility
|
OP
|
$11,795.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,533.40 |
| Max. Negotiated Rate |
$11,323.56 |
| Rate for Payer: Aetna Commercial |
$9,082.44
|
| Rate for Payer: Anthem Medicaid |
$4,056.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,200.40
|
| Rate for Payer: Cash Price |
$5,897.69
|
| Rate for Payer: Cigna Commercial |
$9,790.17
|
| Rate for Payer: First Health Commercial |
$11,205.61
|
| Rate for Payer: Humana Commercial |
$10,026.07
|
| Rate for Payer: Humana KY Medicaid |
$4,056.43
|
| Rate for Payer: Kentucky WC Medicaid |
$4,097.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,672.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,704.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,538.61
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,137.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,379.93
|
| Rate for Payer: Ohio Health Group HMO |
$8,846.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,359.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,533.40
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,656.57
|
| Rate for Payer: PHCS Commercial |
$11,323.56
|
| Rate for Payer: United Healthcare All Payer |
$10,379.93
|
|
|
LINER R3 20 XLPE ACET 40*64
|
Facility
|
OP
|
$13,294.54
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,728.29 |
| Max. Negotiated Rate |
$12,762.76 |
| Rate for Payer: Aetna Commercial |
$10,236.80
|
| Rate for Payer: Anthem Medicaid |
$4,571.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,369.74
|
| Rate for Payer: Cash Price |
$6,647.27
|
| Rate for Payer: Cigna Commercial |
$11,034.47
|
| Rate for Payer: First Health Commercial |
$12,629.81
|
| Rate for Payer: Humana Commercial |
$11,300.36
|
| Rate for Payer: Humana KY Medicaid |
$4,571.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,618.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,901.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,811.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,988.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,663.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,699.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,970.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,658.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,728.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,121.31
|
| Rate for Payer: PHCS Commercial |
$12,762.76
|
| Rate for Payer: United Healthcare All Payer |
$11,699.20
|
|
|
LINER R3 20 XLPE ACET 40*64
|
Facility
|
IP
|
$13,294.54
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,728.29 |
| Max. Negotiated Rate |
$12,762.76 |
| Rate for Payer: Aetna Commercial |
$10,236.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,369.74
|
| Rate for Payer: Cash Price |
$6,647.27
|
| Rate for Payer: Cigna Commercial |
$11,034.47
|
| Rate for Payer: First Health Commercial |
$12,629.81
|
| Rate for Payer: Humana Commercial |
$11,300.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,901.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,811.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,988.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,699.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,970.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,658.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,728.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,121.31
|
| Rate for Payer: PHCS Commercial |
$12,762.76
|
| Rate for Payer: United Healthcare All Payer |
$11,699.20
|
|
|
LINER R3 20 XLPE ACET 40*66/70
|
Facility
|
OP
|
$13,294.54
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,728.29 |
| Max. Negotiated Rate |
$12,762.76 |
| Rate for Payer: Aetna Commercial |
$10,236.80
|
| Rate for Payer: Anthem Medicaid |
$4,571.99
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,369.74
|
| Rate for Payer: Cash Price |
$6,647.27
|
| Rate for Payer: Cigna Commercial |
$11,034.47
|
| Rate for Payer: First Health Commercial |
$12,629.81
|
| Rate for Payer: Humana Commercial |
$11,300.36
|
| Rate for Payer: Humana KY Medicaid |
$4,571.99
|
| Rate for Payer: Kentucky WC Medicaid |
$4,618.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,901.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,811.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,988.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,663.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,699.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,970.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,658.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,728.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,121.31
|
| Rate for Payer: PHCS Commercial |
$12,762.76
|
| Rate for Payer: United Healthcare All Payer |
$11,699.20
|
|
|
LINER R3 20 XLPE ACET 40*66/70
|
Facility
|
IP
|
$13,294.54
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,728.29 |
| Max. Negotiated Rate |
$12,762.76 |
| Rate for Payer: Aetna Commercial |
$10,236.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,369.74
|
| Rate for Payer: Cash Price |
$6,647.27
|
| Rate for Payer: Cigna Commercial |
$11,034.47
|
| Rate for Payer: First Health Commercial |
$12,629.81
|
| Rate for Payer: Humana Commercial |
$11,300.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,901.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,811.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,988.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,699.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,970.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,658.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,728.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,121.31
|
| Rate for Payer: PHCS Commercial |
$12,762.76
|
| Rate for Payer: United Healthcare All Payer |
$11,699.20
|
|
|
LINER R3 20 XLPE ACET 40*72/74
|
Facility
|
OP
|
$15,043.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,955.64 |
| Max. Negotiated Rate |
$14,441.64 |
| Rate for Payer: Aetna Commercial |
$11,583.40
|
| Rate for Payer: Anthem Medicaid |
$5,173.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,733.84
|
| Rate for Payer: Cash Price |
$7,521.69
|
| Rate for Payer: Cigna Commercial |
$12,486.01
|
| Rate for Payer: First Health Commercial |
$14,291.21
|
| Rate for Payer: Humana Commercial |
$12,786.87
|
| Rate for Payer: Humana KY Medicaid |
$5,173.42
|
| Rate for Payer: Kentucky WC Medicaid |
$5,226.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,335.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,102.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,513.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,277.22
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,238.17
|
| Rate for Payer: Ohio Health Group HMO |
$11,282.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,008.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,955.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,663.45
|
| Rate for Payer: PHCS Commercial |
$14,441.64
|
| Rate for Payer: United Healthcare All Payer |
$13,238.17
|
|
|
LINER R3 20 XLPE ACET 40*72/74
|
Facility
|
IP
|
$15,043.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,955.64 |
| Max. Negotiated Rate |
$14,441.64 |
| Rate for Payer: Aetna Commercial |
$11,583.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,733.84
|
| Rate for Payer: Cash Price |
$7,521.69
|
| Rate for Payer: Cigna Commercial |
$12,486.01
|
| Rate for Payer: First Health Commercial |
$14,291.21
|
| Rate for Payer: Humana Commercial |
$12,786.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,335.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,102.01
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,513.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,238.17
|
| Rate for Payer: Ohio Health Group HMO |
$11,282.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,008.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,955.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,663.45
|
| Rate for Payer: PHCS Commercial |
$14,441.64
|
| Rate for Payer: United Healthcare All Payer |
$13,238.17
|
|
