|
MESH FLEXHD PLIABLE PRE THIN L
|
Facility
|
IP
|
$78,638.49
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,223.00 |
| Max. Negotiated Rate |
$75,492.95 |
| Rate for Payer: Aetna Commercial |
$60,551.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$61,338.02
|
| Rate for Payer: Cash Price |
$39,319.24
|
| Rate for Payer: Cigna Commercial |
$65,269.95
|
| Rate for Payer: First Health Commercial |
$74,706.57
|
| Rate for Payer: Humana Commercial |
$66,842.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$64,483.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58,035.21
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,591.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$69,201.87
|
| Rate for Payer: Ohio Health Group HMO |
$58,978.87
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,727.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,223.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,377.93
|
| Rate for Payer: PHCS Commercial |
$75,492.95
|
| Rate for Payer: United Healthcare All Payer |
$69,201.87
|
|
|
MESH FLEXHD PLIABLE PRE THIN M
|
Facility
|
OP
|
$74,860.00
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,731.80 |
| Max. Negotiated Rate |
$71,865.60 |
| Rate for Payer: Aetna Commercial |
$57,642.20
|
| Rate for Payer: Anthem Medicaid |
$25,744.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,390.80
|
| Rate for Payer: Cash Price |
$37,430.00
|
| Rate for Payer: Cigna Commercial |
$62,133.80
|
| Rate for Payer: First Health Commercial |
$71,117.00
|
| Rate for Payer: Humana Commercial |
$63,631.00
|
| Rate for Payer: Humana KY Medicaid |
$25,744.35
|
| Rate for Payer: Kentucky WC Medicaid |
$26,006.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,385.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,246.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,458.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$26,260.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,876.80
|
| Rate for Payer: Ohio Health Group HMO |
$56,145.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,972.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,731.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,206.60
|
| Rate for Payer: PHCS Commercial |
$71,865.60
|
| Rate for Payer: United Healthcare All Payer |
$65,876.80
|
|
|
MESH FLEXHD PLIABLE PRE THIN M
|
Facility
|
IP
|
$74,860.00
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$9,731.80 |
| Max. Negotiated Rate |
$71,865.60 |
| Rate for Payer: Aetna Commercial |
$57,642.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58,390.80
|
| Rate for Payer: Cash Price |
$37,430.00
|
| Rate for Payer: Cigna Commercial |
$62,133.80
|
| Rate for Payer: First Health Commercial |
$71,117.00
|
| Rate for Payer: Humana Commercial |
$63,631.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61,385.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55,246.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22,458.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$65,876.80
|
| Rate for Payer: Ohio Health Group HMO |
$56,145.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,972.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,731.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23,206.60
|
| Rate for Payer: PHCS Commercial |
$71,865.60
|
| Rate for Payer: United Healthcare All Payer |
$65,876.80
|
|
|
MESH FLEXHD PLIABLE PRE THIN S
|
Facility
|
OP
|
$68,794.00
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,943.22 |
| Max. Negotiated Rate |
$66,042.24 |
| Rate for Payer: Aetna Commercial |
$52,971.38
|
| Rate for Payer: Anthem Medicaid |
$23,658.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,659.32
|
| Rate for Payer: Cash Price |
$34,397.00
|
| Rate for Payer: Cigna Commercial |
$57,099.02
|
| Rate for Payer: First Health Commercial |
$65,354.30
|
| Rate for Payer: Humana Commercial |
$58,474.90
|
| Rate for Payer: Humana KY Medicaid |
$23,658.26
|
| Rate for Payer: Kentucky WC Medicaid |
$23,899.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,411.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,769.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,638.20
|
| Rate for Payer: Molina Healthcare Medicaid |
$24,132.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,538.72
|
| Rate for Payer: Ohio Health Group HMO |
$51,595.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,758.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,943.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,326.14
|
| Rate for Payer: PHCS Commercial |
$66,042.24
|
| Rate for Payer: United Healthcare All Payer |
$60,538.72
|
|
|
MESH FLEXHD PLIABLE PRE THIN S
|
Facility
|
IP
|
$68,794.00
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$8,943.22 |
| Max. Negotiated Rate |
$66,042.24 |
| Rate for Payer: Aetna Commercial |
$52,971.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$53,659.32
|
| Rate for Payer: Cash Price |
$34,397.00
|
| Rate for Payer: Cigna Commercial |
$57,099.02
|
| Rate for Payer: First Health Commercial |
$65,354.30
|
| Rate for Payer: Humana Commercial |
$58,474.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$56,411.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$50,769.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$20,638.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$60,538.72
|
| Rate for Payer: Ohio Health Group HMO |
$51,595.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,758.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,943.22
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$21,326.14
|
| Rate for Payer: PHCS Commercial |
$66,042.24
|
| Rate for Payer: United Healthcare All Payer |
$60,538.72
|
|
|
MESH FLEXHD PLIABLE PRE THN XL
|
Facility
|
IP
|
$79,899.50
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,386.94 |
| Max. Negotiated Rate |
$76,703.52 |
| Rate for Payer: Aetna Commercial |
$61,522.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62,321.61
|
| Rate for Payer: Cash Price |
$39,949.75
|
| Rate for Payer: Cigna Commercial |
$66,316.58
|
| Rate for Payer: First Health Commercial |
$75,904.52
|
| Rate for Payer: Humana Commercial |
$67,914.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65,517.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58,965.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,969.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$70,311.56
|
| Rate for Payer: Ohio Health Group HMO |
$59,924.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,979.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,386.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,768.84
|
| Rate for Payer: PHCS Commercial |
$76,703.52
|
| Rate for Payer: United Healthcare All Payer |
$70,311.56
|
|
|
MESH FLEXHD PLIABLE PRE THN XL
|
Facility
|
OP
|
$79,899.50
|
|
|
Service Code
|
HCPCS Q4128
|
| Hospital Charge Code |
27000124
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$10,386.94 |
| Max. Negotiated Rate |
$76,703.52 |
| Rate for Payer: Aetna Commercial |
$61,522.62
|
| Rate for Payer: Anthem Medicaid |
$27,477.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$62,321.61
|
| Rate for Payer: Cash Price |
$39,949.75
|
| Rate for Payer: Cigna Commercial |
$66,316.58
|
| Rate for Payer: First Health Commercial |
$75,904.52
|
| Rate for Payer: Humana Commercial |
$67,914.58
|
| Rate for Payer: Humana KY Medicaid |
$27,477.44
|
| Rate for Payer: Kentucky WC Medicaid |
$27,757.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$65,517.59
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$58,965.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$23,969.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$28,028.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$70,311.56
|
| Rate for Payer: Ohio Health Group HMO |
$59,924.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15,979.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,386.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$24,768.84
|
| Rate for Payer: PHCS Commercial |
$76,703.52
|
| Rate for Payer: United Healthcare All Payer |
$70,311.56
|
|
|
MESH GALAFLEX 3D
|
Facility
|
OP
|
$16,440.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,137.20 |
| Max. Negotiated Rate |
$15,782.40 |
| Rate for Payer: Aetna Commercial |
$12,658.80
|
| Rate for Payer: Anthem Medicaid |
$5,653.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,823.20
|
| Rate for Payer: Cash Price |
$8,220.00
|
| Rate for Payer: Cigna Commercial |
$13,645.20
|
| Rate for Payer: First Health Commercial |
$15,618.00
|
| Rate for Payer: Humana Commercial |
$13,974.00
|
| Rate for Payer: Humana KY Medicaid |
$5,653.72
|
| Rate for Payer: Kentucky WC Medicaid |
$5,711.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,480.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,132.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,932.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,767.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,467.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,330.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,288.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,137.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,096.40
|
| Rate for Payer: PHCS Commercial |
$15,782.40
|
| Rate for Payer: United Healthcare All Payer |
$14,467.20
|
|
|
MESH GALAFLEX 3D
|
Facility
|
IP
|
$16,440.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,137.20 |
| Max. Negotiated Rate |
$15,782.40 |
| Rate for Payer: Aetna Commercial |
$12,658.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,823.20
|
| Rate for Payer: Cash Price |
$8,220.00
|
| Rate for Payer: Cigna Commercial |
$13,645.20
|
| Rate for Payer: First Health Commercial |
$15,618.00
|
| Rate for Payer: Humana Commercial |
$13,974.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,480.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,132.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,932.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,467.20
|
| Rate for Payer: Ohio Health Group HMO |
$12,330.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,288.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,137.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,096.40
|
| Rate for Payer: PHCS Commercial |
$15,782.40
|
| Rate for Payer: United Healthcare All Payer |
$14,467.20
|
|
|
MESH GALAFORM 3D OVL 5.3*15.5C
|
Facility
|
OP
|
$12,790.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.70 |
| Max. Negotiated Rate |
$12,278.40 |
| Rate for Payer: Aetna Commercial |
$9,848.30
|
| Rate for Payer: Anthem Medicaid |
$4,398.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,976.20
|
| Rate for Payer: Cash Price |
$6,395.00
|
| Rate for Payer: Cigna Commercial |
$10,615.70
|
| Rate for Payer: First Health Commercial |
$12,150.50
|
| Rate for Payer: Humana Commercial |
$10,871.50
|
| Rate for Payer: Humana KY Medicaid |
$4,398.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,443.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,487.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,439.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,837.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,486.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,255.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,558.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.90
|
| Rate for Payer: PHCS Commercial |
$12,278.40
|
| Rate for Payer: United Healthcare All Payer |
$11,255.20
|
|
|
MESH GALAFORM 3D OVL 5.3*15.5C
|
Facility
|
IP
|
$12,790.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,662.70 |
| Max. Negotiated Rate |
$12,278.40 |
| Rate for Payer: Aetna Commercial |
$9,848.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,976.20
|
| Rate for Payer: Cash Price |
$6,395.00
|
| Rate for Payer: Cigna Commercial |
$10,615.70
|
| Rate for Payer: First Health Commercial |
$12,150.50
|
| Rate for Payer: Humana Commercial |
$10,871.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,487.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,439.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,837.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,255.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,592.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,558.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,662.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,964.90
|
| Rate for Payer: PHCS Commercial |
$12,278.40
|
| Rate for Payer: United Healthcare All Payer |
$11,255.20
|
|
|
MESH GALAFORM 3D OVL 6.4*18.5C
|
Facility
|
IP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
MESH GALAFORM 3D OVL 6.4*18.5C
|
Facility
|
OP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem Medicaid |
$4,649.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Humana KY Medicaid |
$4,649.53
|
| Rate for Payer: Kentucky WC Medicaid |
$4,696.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
MESH GALAFORM 3D OVL 7.5*21.0C
|
Facility
|
OP
|
$15,000.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$14,400.00 |
| Rate for Payer: Aetna Commercial |
$11,550.00
|
| Rate for Payer: Anthem Medicaid |
$5,158.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,700.00
|
| Rate for Payer: Cash Price |
$7,500.00
|
| Rate for Payer: Cigna Commercial |
$12,450.00
|
| Rate for Payer: First Health Commercial |
$14,250.00
|
| Rate for Payer: Humana Commercial |
$12,750.00
|
| Rate for Payer: Humana KY Medicaid |
$5,158.50
|
| Rate for Payer: Kentucky WC Medicaid |
$5,211.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,300.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,070.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,262.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,650.00
|
| Rate for Payer: PHCS Commercial |
$14,400.00
|
| Rate for Payer: United Healthcare All Payer |
$13,200.00
|
|
|
MESH GALAFORM 3D OVL 7.5*21.0C
|
Facility
|
IP
|
$15,000.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$14,400.00 |
| Rate for Payer: Aetna Commercial |
$11,550.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,700.00
|
| Rate for Payer: Cash Price |
$7,500.00
|
| Rate for Payer: Cigna Commercial |
$12,450.00
|
| Rate for Payer: First Health Commercial |
$14,250.00
|
| Rate for Payer: Humana Commercial |
$12,750.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,300.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,070.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,650.00
|
| Rate for Payer: PHCS Commercial |
$14,400.00
|
| Rate for Payer: United Healthcare All Payer |
$13,200.00
|
|
|
MESH GALAFORM 3D OVL LG FR3D05
|
Facility
|
IP
|
$11,147.50
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.18 |
| Max. Negotiated Rate |
$10,701.60 |
| Rate for Payer: Aetna Commercial |
$8,583.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,695.05
|
| Rate for Payer: Cash Price |
$5,573.75
|
| Rate for Payer: Cigna Commercial |
$9,252.42
|
| Rate for Payer: First Health Commercial |
$10,590.12
|
| Rate for Payer: Humana Commercial |
$9,475.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,140.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,226.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,344.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,809.80
|
| Rate for Payer: Ohio Health Group HMO |
$8,360.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,229.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,449.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.72
|
| Rate for Payer: PHCS Commercial |
$10,701.60
|
| Rate for Payer: United Healthcare All Payer |
$9,809.80
|
|
|
MESH GALAFORM 3D OVL LG FR3D05
|
Facility
|
OP
|
$11,147.50
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,449.18 |
| Max. Negotiated Rate |
$10,701.60 |
| Rate for Payer: Aetna Commercial |
$8,583.58
|
| Rate for Payer: Anthem Medicaid |
$3,833.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,695.05
|
| Rate for Payer: Cash Price |
$5,573.75
|
| Rate for Payer: Cigna Commercial |
$9,252.42
|
| Rate for Payer: First Health Commercial |
$10,590.12
|
| Rate for Payer: Humana Commercial |
$9,475.38
|
| Rate for Payer: Humana KY Medicaid |
$3,833.63
|
| Rate for Payer: Kentucky WC Medicaid |
$3,872.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,140.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,226.86
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,344.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,910.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,809.80
|
| Rate for Payer: Ohio Health Group HMO |
$8,360.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,229.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,449.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.72
|
| Rate for Payer: PHCS Commercial |
$10,701.60
|
| Rate for Payer: United Healthcare All Payer |
$9,809.80
|
|
|
MESH GALAFORM 3D OVL MED FR3D0
|
Facility
|
OP
|
$7,910.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,028.30 |
| Max. Negotiated Rate |
$7,593.60 |
| Rate for Payer: Aetna Commercial |
$6,090.70
|
| Rate for Payer: Anthem Medicaid |
$2,720.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,169.80
|
| Rate for Payer: Cash Price |
$3,955.00
|
| Rate for Payer: Cigna Commercial |
$6,565.30
|
| Rate for Payer: First Health Commercial |
$7,514.50
|
| Rate for Payer: Humana Commercial |
$6,723.50
|
| Rate for Payer: Humana KY Medicaid |
$2,720.25
|
| Rate for Payer: Kentucky WC Medicaid |
$2,747.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,486.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,837.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,373.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,774.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,960.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,932.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,582.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,028.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,452.10
|
| Rate for Payer: PHCS Commercial |
$7,593.60
|
| Rate for Payer: United Healthcare All Payer |
$6,960.80
|
|
|
MESH GALAFORM 3D OVL MED FR3D0
|
Facility
|
IP
|
$7,910.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,028.30 |
| Max. Negotiated Rate |
$7,593.60 |
| Rate for Payer: Aetna Commercial |
$6,090.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,169.80
|
| Rate for Payer: Cash Price |
$3,955.00
|
| Rate for Payer: Cigna Commercial |
$6,565.30
|
| Rate for Payer: First Health Commercial |
$7,514.50
|
| Rate for Payer: Humana Commercial |
$6,723.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,486.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,837.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,373.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,960.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,932.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,582.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,028.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,452.10
|
| Rate for Payer: PHCS Commercial |
$7,593.60
|
| Rate for Payer: United Healthcare All Payer |
$6,960.80
|
|
|
MESH GALAFORM SCAFFLD 18*10.1C
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
MESH GALAFORM SCAFFLD 18*10.1C
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
MESH GALAFORM SCAFFOLD 10*20CM
|
Facility
|
IP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
MESH GALAFORM SCAFFOLD 10*20CM
|
Facility
|
OP
|
$13,520.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,757.60 |
| Max. Negotiated Rate |
$12,979.20 |
| Rate for Payer: Aetna Commercial |
$10,410.40
|
| Rate for Payer: Anthem Medicaid |
$4,649.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,545.60
|
| Rate for Payer: Cash Price |
$6,760.00
|
| Rate for Payer: Cigna Commercial |
$11,221.60
|
| Rate for Payer: First Health Commercial |
$12,844.00
|
| Rate for Payer: Humana Commercial |
$11,492.00
|
| Rate for Payer: Humana KY Medicaid |
$4,649.53
|
| Rate for Payer: Kentucky WC Medicaid |
$4,696.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,086.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,977.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,056.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,742.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,897.60
|
| Rate for Payer: Ohio Health Group HMO |
$10,140.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,704.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,757.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,191.20
|
| Rate for Payer: PHCS Commercial |
$12,979.20
|
| Rate for Payer: United Healthcare All Payer |
$11,897.60
|
|
|
MESH GALAFORM SCAFFOLD 15*20CM
|
Facility
|
IP
|
$10,600.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,378.00 |
| Max. Negotiated Rate |
$10,176.00 |
| Rate for Payer: Aetna Commercial |
$8,162.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,268.00
|
| Rate for Payer: Cash Price |
$5,300.00
|
| Rate for Payer: Cigna Commercial |
$8,798.00
|
| Rate for Payer: First Health Commercial |
$10,070.00
|
| Rate for Payer: Humana Commercial |
$9,010.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,692.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,822.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,180.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,328.00
|
| Rate for Payer: Ohio Health Group HMO |
$7,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,378.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,286.00
|
| Rate for Payer: PHCS Commercial |
$10,176.00
|
| Rate for Payer: United Healthcare All Payer |
$9,328.00
|
|
|
MESH GALAFORM SCAFFOLD 15*20CM
|
Facility
|
OP
|
$10,600.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,378.00 |
| Max. Negotiated Rate |
$10,176.00 |
| Rate for Payer: Aetna Commercial |
$8,162.00
|
| Rate for Payer: Anthem Medicaid |
$3,645.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,268.00
|
| Rate for Payer: Cash Price |
$5,300.00
|
| Rate for Payer: Cigna Commercial |
$8,798.00
|
| Rate for Payer: First Health Commercial |
$10,070.00
|
| Rate for Payer: Humana Commercial |
$9,010.00
|
| Rate for Payer: Humana KY Medicaid |
$3,645.34
|
| Rate for Payer: Kentucky WC Medicaid |
$3,682.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,692.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,822.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,180.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,718.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,328.00
|
| Rate for Payer: Ohio Health Group HMO |
$7,950.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,120.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,378.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,286.00
|
| Rate for Payer: PHCS Commercial |
$10,176.00
|
| Rate for Payer: United Healthcare All Payer |
$9,328.00
|
|
