|
LINER MDM 48MM G
|
Facility
|
IP
|
$11,353.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,406.14 |
| Max. Negotiated Rate |
$10,899.65 |
| Rate for Payer: Aetna Commercial |
$8,742.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,855.96
|
| Rate for Payer: Cash Price |
$5,676.90
|
| Rate for Payer: Cigna Commercial |
$9,423.65
|
| Rate for Payer: First Health Commercial |
$10,786.11
|
| Rate for Payer: Humana Commercial |
$9,650.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,310.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,379.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,406.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,991.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,515.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,083.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,877.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,834.12
|
| Rate for Payer: PHCS Commercial |
$10,899.65
|
| Rate for Payer: United Healthcare All Payer |
$9,991.34
|
|
|
LINER MDM 48MM G
|
Facility
|
OP
|
$11,353.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,406.14 |
| Max. Negotiated Rate |
$10,899.65 |
| Rate for Payer: Aetna Commercial |
$8,742.43
|
| Rate for Payer: Anthem Medicaid |
$3,904.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,855.96
|
| Rate for Payer: Cash Price |
$5,676.90
|
| Rate for Payer: Cigna Commercial |
$9,423.65
|
| Rate for Payer: First Health Commercial |
$10,786.11
|
| Rate for Payer: Humana Commercial |
$9,650.73
|
| Rate for Payer: Humana KY Medicaid |
$3,904.57
|
| Rate for Payer: Kentucky WC Medicaid |
$3,944.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,310.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,379.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,406.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,982.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,991.34
|
| Rate for Payer: Ohio Health Group HMO |
$8,515.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,083.04
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,877.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,834.12
|
| Rate for Payer: PHCS Commercial |
$10,899.65
|
| Rate for Payer: United Healthcare All Payer |
$9,991.34
|
|
|
LINER POLY 40MM ID 62MM
|
Facility
|
IP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
LINER POLY 40MM ID 62MM
|
Facility
|
OP
|
$4,625.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,387.50 |
| Max. Negotiated Rate |
$4,440.00 |
| Rate for Payer: Aetna Commercial |
$3,561.25
|
| Rate for Payer: Anthem Medicaid |
$1,590.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,607.50
|
| Rate for Payer: Cash Price |
$2,312.50
|
| Rate for Payer: Cigna Commercial |
$3,838.75
|
| Rate for Payer: First Health Commercial |
$4,393.75
|
| Rate for Payer: Humana Commercial |
$3,931.25
|
| Rate for Payer: Humana KY Medicaid |
$1,590.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1,606.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,792.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,413.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,387.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,622.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,070.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,468.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,700.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,023.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,191.25
|
| Rate for Payer: PHCS Commercial |
$4,440.00
|
| Rate for Payer: United Healthcare All Payer |
$4,070.00
|
|
|
LINER R3 0^ +4 XLPE ACE 44*60
|
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 R3 0^ +4 XLPE ACE 44*60
|
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 R3 0^ +4 XLPE ACE 44*62
|
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 R3 0^ +4 XLPE ACE 44*62
|
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 R3 0^ +4 XLPE ACE 44*64
|
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 R3 0^ +4 XLPE ACE 44*64
|
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 R3 0 +4 XLPE ACET 40*56
|
Facility
|
IP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*56
|
Facility
|
OP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem Medicaid |
$4,659.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Humana KY Medicaid |
$4,659.60
|
| Rate for Payer: Kentucky WC Medicaid |
$4,707.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,753.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*58
|
Facility
|
IP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*58
|
Facility
|
OP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem Medicaid |
$4,659.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Humana KY Medicaid |
$4,659.60
|
| Rate for Payer: Kentucky WC Medicaid |
$4,707.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,753.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*60
|
Facility
|
IP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*60
|
Facility
|
OP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem Medicaid |
$4,659.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Humana KY Medicaid |
$4,659.60
|
| Rate for Payer: Kentucky WC Medicaid |
$4,707.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,753.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*62
|
Facility
|
OP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem Medicaid |
$4,659.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Humana KY Medicaid |
$4,659.60
|
| Rate for Payer: Kentucky WC Medicaid |
$4,707.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,753.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*62
|
Facility
|
IP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*64
|
Facility
|
OP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem Medicaid |
$4,659.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Humana KY Medicaid |
$4,659.60
|
| Rate for Payer: Kentucky WC Medicaid |
$4,707.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,753.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 +4 XLPE ACET 40*64
|
Facility
|
IP
|
$13,549.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,064.79 |
| Max. Negotiated Rate |
$13,007.33 |
| Rate for Payer: Aetna Commercial |
$10,432.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,568.45
|
| Rate for Payer: Cash Price |
$6,774.65
|
| Rate for Payer: Cigna Commercial |
$11,245.92
|
| Rate for Payer: First Health Commercial |
$12,871.83
|
| Rate for Payer: Humana Commercial |
$11,516.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,110.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,999.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,064.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,923.38
|
| Rate for Payer: Ohio Health Group HMO |
$10,161.98
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,839.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,787.89
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,349.02
|
| Rate for Payer: PHCS Commercial |
$13,007.33
|
| Rate for Payer: United Healthcare All Payer |
$11,923.38
|
|
|
LINER R3 0 ACET 40MM 56MM OD
|
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 R3 0 ACET 40MM 56MM OD
|
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 R3 0 XLPE 40MM 76*80 OD
|
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 R3 0 XLPE 40MM 76*80 OD
|
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 R3 0 XLPE+4 40MM 76*80OD
|
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
|
|
