|
LINER R3 0 XLPE ACET 40MM*64MM
|
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 ACET 40MM*64MM
|
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 20^+4 XLPACET36*66/68
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^+4 XLPACET36*66/68
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^ +4 XLPE 36*72-74
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^ +4 XLPE 36*72-74
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^ +4 XLPE 36*76-80
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^ +4 XLPE 36*76-80
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
LINER R3 20^ +4 XLPE 40*66/70
|
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 20^ +4 XLPE 40*66/70
|
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 20^ +4 XLPE 40*72-74
|
Facility
|
IP
|
$15,546.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.88 |
| Max. Negotiated Rate |
$14,924.40 |
| Rate for Payer: Aetna Commercial |
$11,970.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,126.08
|
| Rate for Payer: Cash Price |
$7,773.12
|
| Rate for Payer: Cigna Commercial |
$12,903.39
|
| Rate for Payer: First Health Commercial |
$14,768.94
|
| Rate for Payer: Humana Commercial |
$13,214.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,747.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,473.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,663.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,680.70
|
| Rate for Payer: Ohio Health Group HMO |
$11,659.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,437.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,525.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,726.91
|
| Rate for Payer: PHCS Commercial |
$14,924.40
|
| Rate for Payer: United Healthcare All Payer |
$13,680.70
|
|
|
LINER R3 20^ +4 XLPE 40*72-74
|
Facility
|
OP
|
$15,546.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,663.88 |
| Max. Negotiated Rate |
$14,924.40 |
| Rate for Payer: Aetna Commercial |
$11,970.61
|
| Rate for Payer: Anthem Medicaid |
$5,346.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,126.08
|
| Rate for Payer: Cash Price |
$7,773.12
|
| Rate for Payer: Cigna Commercial |
$12,903.39
|
| Rate for Payer: First Health Commercial |
$14,768.94
|
| Rate for Payer: Humana Commercial |
$13,214.31
|
| Rate for Payer: Humana KY Medicaid |
$5,346.36
|
| Rate for Payer: Kentucky WC Medicaid |
$5,400.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,747.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,473.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,663.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,453.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,680.70
|
| Rate for Payer: Ohio Health Group HMO |
$11,659.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,437.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,525.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,726.91
|
| Rate for Payer: PHCS Commercial |
$14,924.40
|
| Rate for Payer: United Healthcare All Payer |
$13,680.70
|
|
|
LINER R3 20^ +4 XLPE 44*66-70
|
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 R3 20^ +4 XLPE 44*66-70
|
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 R3 20^ +4 XLPE 44*72-74
|
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 R3 20^ +4 XLPE 44*72-74
|
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 R3 20^ +4 XLPE 44*76-80
|
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 20^ +4 XLPE 44*76-80
|
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 20^ +4 XLPE ACE 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 20^ +4 XLPE ACE 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 20^ +4 XLPE ACE 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 20^ +4 XLPE ACE 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 20^ +4 XLPE ACE 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 20^ +4 XLPE ACE 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 20^ +4 XLPE ACE 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
|
|
