|
MESH ALLODRM PRF CONT 9.6*19.3
|
Facility
|
OP
|
$18,589.50
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
27000077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,576.85 |
| Max. Negotiated Rate |
$17,845.92 |
| Rate for Payer: Aetna Commercial |
$14,313.92
|
| Rate for Payer: Anthem Medicaid |
$6,392.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,499.81
|
| Rate for Payer: Cash Price |
$9,294.75
|
| Rate for Payer: Cigna Commercial |
$15,429.28
|
| Rate for Payer: First Health Commercial |
$17,660.03
|
| Rate for Payer: Humana Commercial |
$15,801.08
|
| Rate for Payer: Humana KY Medicaid |
$6,392.93
|
| Rate for Payer: Kentucky WC Medicaid |
$6,457.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,243.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,719.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,576.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,521.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,358.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,942.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,871.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,172.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,826.75
|
| Rate for Payer: PHCS Commercial |
$17,845.92
|
| Rate for Payer: United Healthcare All Payer |
$16,358.76
|
|
|
MESH ALLODRM PRF CONT 9.6*19.3
|
Facility
|
IP
|
$18,589.50
|
|
|
Service Code
|
HCPCS Q4116
|
| Hospital Charge Code |
27000077
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,576.85 |
| Max. Negotiated Rate |
$17,845.92 |
| Rate for Payer: Aetna Commercial |
$14,313.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,499.81
|
| Rate for Payer: Cash Price |
$9,294.75
|
| Rate for Payer: Cigna Commercial |
$15,429.28
|
| Rate for Payer: First Health Commercial |
$17,660.03
|
| Rate for Payer: Humana Commercial |
$15,801.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,243.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,719.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,576.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,358.76
|
| Rate for Payer: Ohio Health Group HMO |
$13,942.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,871.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,172.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,826.75
|
| Rate for Payer: PHCS Commercial |
$17,845.92
|
| Rate for Payer: United Healthcare All Payer |
$16,358.76
|
|
|
MESH BILAYER WOUND MATRIX 2*2
|
Facility
|
OP
|
$23,465.00
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,039.50 |
| Max. Negotiated Rate |
$22,526.40 |
| Rate for Payer: Aetna Commercial |
$18,068.05
|
| Rate for Payer: Anthem Medicaid |
$8,069.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,302.70
|
| Rate for Payer: Cash Price |
$11,732.50
|
| Rate for Payer: Cigna Commercial |
$19,475.95
|
| Rate for Payer: First Health Commercial |
$22,291.75
|
| Rate for Payer: Humana Commercial |
$19,945.25
|
| Rate for Payer: Humana KY Medicaid |
$8,069.61
|
| Rate for Payer: Kentucky WC Medicaid |
$8,151.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,241.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,317.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,039.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,231.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,598.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,772.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,414.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,190.85
|
| Rate for Payer: PHCS Commercial |
$22,526.40
|
| Rate for Payer: United Healthcare All Payer |
$20,649.20
|
|
|
MESH BILAYER WOUND MATRIX 2*2
|
Facility
|
IP
|
$23,465.00
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,039.50 |
| Max. Negotiated Rate |
$22,526.40 |
| Rate for Payer: Aetna Commercial |
$18,068.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,302.70
|
| Rate for Payer: Cash Price |
$11,732.50
|
| Rate for Payer: Cigna Commercial |
$19,475.95
|
| Rate for Payer: First Health Commercial |
$22,291.75
|
| Rate for Payer: Humana Commercial |
$19,945.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,241.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,317.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,039.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,598.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,772.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,414.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,190.85
|
| Rate for Payer: PHCS Commercial |
$22,526.40
|
| Rate for Payer: United Healthcare All Payer |
$20,649.20
|
|
|
MESH BILAYER WOUND MATRIX 4*10
|
Facility
|
OP
|
$25,343.75
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,603.12 |
| Max. Negotiated Rate |
$24,330.00 |
| Rate for Payer: Aetna Commercial |
$19,514.69
|
| Rate for Payer: Anthem Medicaid |
$8,715.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,768.12
|
| Rate for Payer: Cash Price |
$12,671.88
|
| Rate for Payer: Cigna Commercial |
$21,035.31
|
| Rate for Payer: First Health Commercial |
$24,076.56
|
| Rate for Payer: Humana Commercial |
$21,542.19
|
| Rate for Payer: Humana KY Medicaid |
$8,715.72
|
| Rate for Payer: Kentucky WC Medicaid |
$8,804.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,781.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,703.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,603.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,890.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,302.50
|
| Rate for Payer: Ohio Health Group HMO |
$19,007.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,275.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,049.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,487.19
|
| Rate for Payer: PHCS Commercial |
$24,330.00
|
| Rate for Payer: United Healthcare All Payer |
$22,302.50
|
|
|
MESH BILAYER WOUND MATRIX 4*10
|
Facility
|
IP
|
$25,343.75
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$7,603.12 |
| Max. Negotiated Rate |
$24,330.00 |
| Rate for Payer: Aetna Commercial |
$19,514.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,768.12
|
| Rate for Payer: Cash Price |
$12,671.88
|
| Rate for Payer: Cigna Commercial |
$21,035.31
|
| Rate for Payer: First Health Commercial |
$24,076.56
|
| Rate for Payer: Humana Commercial |
$21,542.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,781.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,703.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,603.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$22,302.50
|
| Rate for Payer: Ohio Health Group HMO |
$19,007.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20,275.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22,049.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17,487.19
|
| Rate for Payer: PHCS Commercial |
$24,330.00
|
| Rate for Payer: United Healthcare All Payer |
$22,302.50
|
|
|
MESH BILAYER WOUND MATRIX 4*5
|
Facility
|
OP
|
$13,900.78
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,170.23 |
| Max. Negotiated Rate |
$13,344.75 |
| Rate for Payer: Aetna Commercial |
$10,703.60
|
| Rate for Payer: Anthem Medicaid |
$4,780.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,842.61
|
| Rate for Payer: Cash Price |
$6,950.39
|
| Rate for Payer: Cigna Commercial |
$11,537.65
|
| Rate for Payer: First Health Commercial |
$13,205.74
|
| Rate for Payer: Humana Commercial |
$11,815.66
|
| Rate for Payer: Humana KY Medicaid |
$4,780.48
|
| Rate for Payer: Kentucky WC Medicaid |
$4,829.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,398.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,258.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,170.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,876.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,232.69
|
| Rate for Payer: Ohio Health Group HMO |
$10,425.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,120.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,093.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,591.54
|
| Rate for Payer: PHCS Commercial |
$13,344.75
|
| Rate for Payer: United Healthcare All Payer |
$12,232.69
|
|
|
MESH BILAYER WOUND MATRIX 4*5
|
Facility
|
IP
|
$13,900.78
|
|
|
Service Code
|
HCPCS C9363
|
| Hospital Charge Code |
27000001
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,170.23 |
| Max. Negotiated Rate |
$13,344.75 |
| Rate for Payer: Aetna Commercial |
$10,703.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,842.61
|
| Rate for Payer: Cash Price |
$6,950.39
|
| Rate for Payer: Cigna Commercial |
$11,537.65
|
| Rate for Payer: First Health Commercial |
$13,205.74
|
| Rate for Payer: Humana Commercial |
$11,815.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,398.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,258.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,170.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,232.69
|
| Rate for Payer: Ohio Health Group HMO |
$10,425.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,120.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,093.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,591.54
|
| Rate for Payer: PHCS Commercial |
$13,344.75
|
| Rate for Payer: United Healthcare All Payer |
$12,232.69
|
|
|
MESH BIO A TISS REINF 10*30CM
|
Facility
|
IP
|
$10,197.80
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,059.34 |
| Max. Negotiated Rate |
$9,789.89 |
| Rate for Payer: Aetna Commercial |
$7,852.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,954.28
|
| Rate for Payer: Cash Price |
$5,098.90
|
| Rate for Payer: Cigna Commercial |
$8,464.17
|
| Rate for Payer: First Health Commercial |
$9,687.91
|
| Rate for Payer: Humana Commercial |
$8,668.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,362.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,525.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,059.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,974.06
|
| Rate for Payer: Ohio Health Group HMO |
$7,648.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,158.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,872.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,036.48
|
| Rate for Payer: PHCS Commercial |
$9,789.89
|
| Rate for Payer: United Healthcare All Payer |
$8,974.06
|
|
|
MESH BIO A TISS REINF 10*30CM
|
Facility
|
OP
|
$10,197.80
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,059.34 |
| Max. Negotiated Rate |
$9,789.89 |
| Rate for Payer: Aetna Commercial |
$7,852.31
|
| Rate for Payer: Anthem Medicaid |
$3,507.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,954.28
|
| Rate for Payer: Cash Price |
$5,098.90
|
| Rate for Payer: Cigna Commercial |
$8,464.17
|
| Rate for Payer: First Health Commercial |
$9,687.91
|
| Rate for Payer: Humana Commercial |
$8,668.13
|
| Rate for Payer: Humana KY Medicaid |
$3,507.02
|
| Rate for Payer: Kentucky WC Medicaid |
$3,542.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,362.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,525.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,059.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,577.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,974.06
|
| Rate for Payer: Ohio Health Group HMO |
$7,648.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,158.24
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,872.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,036.48
|
| Rate for Payer: PHCS Commercial |
$9,789.89
|
| Rate for Payer: United Healthcare All Payer |
$8,974.06
|
|
|
MESH BIO A TISS REINF 20*20CM
|
Facility
|
IP
|
$13,159.44
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,947.83 |
| Max. Negotiated Rate |
$12,633.06 |
| Rate for Payer: Aetna Commercial |
$10,132.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,264.36
|
| Rate for Payer: Cash Price |
$6,579.72
|
| Rate for Payer: Cigna Commercial |
$10,922.34
|
| Rate for Payer: First Health Commercial |
$12,501.47
|
| Rate for Payer: Humana Commercial |
$11,185.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,790.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,711.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,947.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,580.31
|
| Rate for Payer: Ohio Health Group HMO |
$9,869.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,527.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,448.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,080.01
|
| Rate for Payer: PHCS Commercial |
$12,633.06
|
| Rate for Payer: United Healthcare All Payer |
$11,580.31
|
|
|
MESH BIO A TISS REINF 20*20CM
|
Facility
|
OP
|
$13,159.44
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,947.83 |
| Max. Negotiated Rate |
$12,633.06 |
| Rate for Payer: Aetna Commercial |
$10,132.77
|
| Rate for Payer: Anthem Medicaid |
$4,525.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,264.36
|
| Rate for Payer: Cash Price |
$6,579.72
|
| Rate for Payer: Cigna Commercial |
$10,922.34
|
| Rate for Payer: First Health Commercial |
$12,501.47
|
| Rate for Payer: Humana Commercial |
$11,185.52
|
| Rate for Payer: Humana KY Medicaid |
$4,525.53
|
| Rate for Payer: Kentucky WC Medicaid |
$4,571.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,790.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,711.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,947.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,616.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,580.31
|
| Rate for Payer: Ohio Health Group HMO |
$9,869.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,527.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,448.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,080.01
|
| Rate for Payer: PHCS Commercial |
$12,633.06
|
| Rate for Payer: United Healthcare All Payer |
$11,580.31
|
|
|
MESH BIO A TISS REINF 8*8CM
|
Facility
|
IP
|
$3,503.75
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,051.12 |
| Max. Negotiated Rate |
$3,363.60 |
| Rate for Payer: Aetna Commercial |
$2,697.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,732.93
|
| Rate for Payer: Cash Price |
$1,751.88
|
| Rate for Payer: Cigna Commercial |
$2,908.11
|
| Rate for Payer: First Health Commercial |
$3,328.56
|
| Rate for Payer: Humana Commercial |
$2,978.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,873.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,585.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,051.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,083.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,627.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,803.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,048.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,417.59
|
| Rate for Payer: PHCS Commercial |
$3,363.60
|
| Rate for Payer: United Healthcare All Payer |
$3,083.30
|
|
|
MESH BIO A TISS REINF 8*8CM
|
Facility
|
OP
|
$3,503.75
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,051.12 |
| Max. Negotiated Rate |
$3,363.60 |
| Rate for Payer: Aetna Commercial |
$2,697.89
|
| Rate for Payer: Anthem Medicaid |
$1,204.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,732.93
|
| Rate for Payer: Cash Price |
$1,751.88
|
| Rate for Payer: Cigna Commercial |
$2,908.11
|
| Rate for Payer: First Health Commercial |
$3,328.56
|
| Rate for Payer: Humana Commercial |
$2,978.19
|
| Rate for Payer: Humana KY Medicaid |
$1,204.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,217.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,873.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,585.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,051.12
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,229.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,083.30
|
| Rate for Payer: Ohio Health Group HMO |
$2,627.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,803.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,048.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,417.59
|
| Rate for Payer: PHCS Commercial |
$3,363.60
|
| Rate for Payer: United Healthcare All Payer |
$3,083.30
|
|
|
MESH BIO A TISS REINF 9*15CM
|
Facility
|
IP
|
$4,685.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,405.50 |
| Max. Negotiated Rate |
$4,497.60 |
| Rate for Payer: Aetna Commercial |
$3,607.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,654.30
|
| Rate for Payer: Cash Price |
$2,342.50
|
| Rate for Payer: Cigna Commercial |
$3,888.55
|
| Rate for Payer: First Health Commercial |
$4,450.75
|
| Rate for Payer: Humana Commercial |
$3,982.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,841.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,457.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,405.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,122.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,513.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,748.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,075.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,232.65
|
| Rate for Payer: PHCS Commercial |
$4,497.60
|
| Rate for Payer: United Healthcare All Payer |
$4,122.80
|
|
|
MESH BIO A TISS REINF 9*15CM
|
Facility
|
OP
|
$4,685.00
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,405.50 |
| Max. Negotiated Rate |
$4,497.60 |
| Rate for Payer: Aetna Commercial |
$3,607.45
|
| Rate for Payer: Anthem Medicaid |
$1,611.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,654.30
|
| Rate for Payer: Cash Price |
$2,342.50
|
| Rate for Payer: Cigna Commercial |
$3,888.55
|
| Rate for Payer: First Health Commercial |
$4,450.75
|
| Rate for Payer: Humana Commercial |
$3,982.25
|
| Rate for Payer: Humana KY Medicaid |
$1,611.17
|
| Rate for Payer: Kentucky WC Medicaid |
$1,627.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,841.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,457.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,405.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,643.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,122.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,513.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,748.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,075.95
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,232.65
|
| Rate for Payer: PHCS Commercial |
$4,497.60
|
| Rate for Payer: United Healthcare All Payer |
$4,122.80
|
|
|
MESH DCELL 214 6*16CM MICROPER
|
Facility
|
OP
|
$14,296.96
|
|
|
Service Code
|
HCPCS Q4122
|
| Hospital Charge Code |
27000078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,289.09 |
| Max. Negotiated Rate |
$13,725.08 |
| Rate for Payer: Aetna Commercial |
$11,008.66
|
| Rate for Payer: Anthem Medicaid |
$4,916.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,151.63
|
| Rate for Payer: Cash Price |
$7,148.48
|
| Rate for Payer: Cigna Commercial |
$11,866.48
|
| Rate for Payer: First Health Commercial |
$13,582.11
|
| Rate for Payer: Humana Commercial |
$12,152.42
|
| Rate for Payer: Humana KY Medicaid |
$4,916.72
|
| Rate for Payer: Kentucky WC Medicaid |
$4,966.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,723.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,551.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,289.09
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,015.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,581.32
|
| Rate for Payer: Ohio Health Group HMO |
$10,722.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,437.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,438.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,864.90
|
| Rate for Payer: PHCS Commercial |
$13,725.08
|
| Rate for Payer: United Healthcare All Payer |
$12,581.32
|
|
|
MESH DCELL 214 6*16CM MICROPER
|
Facility
|
IP
|
$14,296.96
|
|
|
Service Code
|
HCPCS Q4122
|
| Hospital Charge Code |
27000078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,289.09 |
| Max. Negotiated Rate |
$13,725.08 |
| Rate for Payer: Aetna Commercial |
$11,008.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,151.63
|
| Rate for Payer: Cash Price |
$7,148.48
|
| Rate for Payer: Cigna Commercial |
$11,866.48
|
| Rate for Payer: First Health Commercial |
$13,582.11
|
| Rate for Payer: Humana Commercial |
$12,152.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,723.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,551.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,289.09
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,581.32
|
| Rate for Payer: Ohio Health Group HMO |
$10,722.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11,437.57
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$12,438.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,864.90
|
| Rate for Payer: PHCS Commercial |
$13,725.08
|
| Rate for Payer: United Healthcare All Payer |
$12,581.32
|
|
|
MESH DCELL 216 8*20CM MICROPER
|
Facility
|
IP
|
$23,386.18
|
|
|
Service Code
|
HCPCS Q4122
|
| Hospital Charge Code |
27000078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,015.85 |
| Max. Negotiated Rate |
$22,450.73 |
| Rate for Payer: Aetna Commercial |
$18,007.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,241.22
|
| Rate for Payer: Cash Price |
$11,693.09
|
| Rate for Payer: Cigna Commercial |
$19,410.53
|
| Rate for Payer: First Health Commercial |
$22,216.87
|
| Rate for Payer: Humana Commercial |
$19,878.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,176.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,259.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,015.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,579.84
|
| Rate for Payer: Ohio Health Group HMO |
$17,539.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,708.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,345.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,136.46
|
| Rate for Payer: PHCS Commercial |
$22,450.73
|
| Rate for Payer: United Healthcare All Payer |
$20,579.84
|
|
|
MESH DCELL 216 8*20CM MICROPER
|
Facility
|
OP
|
$23,386.18
|
|
|
Service Code
|
HCPCS Q4122
|
| Hospital Charge Code |
27000078
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,015.85 |
| Max. Negotiated Rate |
$22,450.73 |
| Rate for Payer: Aetna Commercial |
$18,007.36
|
| Rate for Payer: Anthem Medicaid |
$8,042.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,241.22
|
| Rate for Payer: Cash Price |
$11,693.09
|
| Rate for Payer: Cigna Commercial |
$19,410.53
|
| Rate for Payer: First Health Commercial |
$22,216.87
|
| Rate for Payer: Humana Commercial |
$19,878.25
|
| Rate for Payer: Humana KY Medicaid |
$8,042.51
|
| Rate for Payer: Kentucky WC Medicaid |
$8,124.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,176.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,259.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,015.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,203.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,579.84
|
| Rate for Payer: Ohio Health Group HMO |
$17,539.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,708.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,345.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,136.46
|
| Rate for Payer: PHCS Commercial |
$22,450.73
|
| Rate for Payer: United Healthcare All Payer |
$20,579.84
|
|
|
MESH DUAL 20CM*30CM
|
Facility
|
OP
|
$8,861.90
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.57 |
| Max. Negotiated Rate |
$8,507.42 |
| Rate for Payer: Aetna Commercial |
$6,823.66
|
| Rate for Payer: Anthem Medicaid |
$3,047.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,912.28
|
| Rate for Payer: Cash Price |
$4,430.95
|
| Rate for Payer: Cigna Commercial |
$7,355.38
|
| Rate for Payer: First Health Commercial |
$8,418.81
|
| Rate for Payer: Humana Commercial |
$7,532.61
|
| Rate for Payer: Humana KY Medicaid |
$3,047.61
|
| Rate for Payer: Kentucky WC Medicaid |
$3,078.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,266.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,540.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,658.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,108.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,798.47
|
| Rate for Payer: Ohio Health Group HMO |
$6,646.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,089.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,709.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,114.71
|
| Rate for Payer: PHCS Commercial |
$8,507.42
|
| Rate for Payer: United Healthcare All Payer |
$7,798.47
|
|
|
MESH DUAL 20CM*30CM
|
Facility
|
IP
|
$8,861.90
|
|
|
Service Code
|
HCPCS C1781
|
| Hospital Charge Code |
27000073
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,658.57 |
| Max. Negotiated Rate |
$8,507.42 |
| Rate for Payer: Aetna Commercial |
$6,823.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,912.28
|
| Rate for Payer: Cash Price |
$4,430.95
|
| Rate for Payer: Cigna Commercial |
$7,355.38
|
| Rate for Payer: First Health Commercial |
$8,418.81
|
| Rate for Payer: Humana Commercial |
$7,532.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,266.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,540.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,658.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,798.47
|
| Rate for Payer: Ohio Health Group HMO |
$6,646.43
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,089.52
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,709.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,114.71
|
| Rate for Payer: PHCS Commercial |
$8,507.42
|
| Rate for Payer: United Healthcare All Payer |
$7,798.47
|
|
|
MESHED BILAYER WND MATRIX 4*10
|
Facility
|
OP
|
$18,567.30
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
27000076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,570.19 |
| Max. Negotiated Rate |
$17,824.61 |
| Rate for Payer: Aetna Commercial |
$14,296.82
|
| Rate for Payer: Anthem Medicaid |
$6,385.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,482.49
|
| Rate for Payer: Cash Price |
$9,283.65
|
| Rate for Payer: Cigna Commercial |
$15,410.86
|
| Rate for Payer: First Health Commercial |
$17,638.94
|
| Rate for Payer: Humana Commercial |
$15,782.20
|
| Rate for Payer: Humana KY Medicaid |
$6,385.29
|
| Rate for Payer: Kentucky WC Medicaid |
$6,450.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,225.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,702.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,570.19
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,513.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,339.22
|
| Rate for Payer: Ohio Health Group HMO |
$13,925.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,853.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,153.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,811.44
|
| Rate for Payer: PHCS Commercial |
$17,824.61
|
| Rate for Payer: United Healthcare All Payer |
$16,339.22
|
|
|
MESHED BILAYER WND MATRIX 4*10
|
Facility
|
IP
|
$18,567.30
|
|
|
Service Code
|
HCPCS Q4105
|
| Hospital Charge Code |
27000076
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,570.19 |
| Max. Negotiated Rate |
$17,824.61 |
| Rate for Payer: Aetna Commercial |
$14,296.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$14,482.49
|
| Rate for Payer: Cash Price |
$9,283.65
|
| Rate for Payer: Cigna Commercial |
$15,410.86
|
| Rate for Payer: First Health Commercial |
$17,638.94
|
| Rate for Payer: Humana Commercial |
$15,782.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$15,225.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$13,702.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,570.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$16,339.22
|
| Rate for Payer: Ohio Health Group HMO |
$13,925.48
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,853.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16,153.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,811.44
|
| Rate for Payer: PHCS Commercial |
$17,824.61
|
| Rate for Payer: United Healthcare All Payer |
$16,339.22
|
|
|
MESHED BILAYER WND MATRIX 4*5
|
Facility
|
OP
|
$13,287.89
|
|
|
Service Code
|
HCPCS Q4104
|
| Hospital Charge Code |
27000075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,986.37 |
| Max. Negotiated Rate |
$12,756.37 |
| Rate for Payer: Aetna Commercial |
$10,231.68
|
| Rate for Payer: Anthem Medicaid |
$4,569.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,364.55
|
| Rate for Payer: Cash Price |
$6,643.94
|
| Rate for Payer: Cigna Commercial |
$11,028.95
|
| Rate for Payer: First Health Commercial |
$12,623.50
|
| Rate for Payer: Humana Commercial |
$11,294.71
|
| Rate for Payer: Humana KY Medicaid |
$4,569.71
|
| Rate for Payer: Kentucky WC Medicaid |
$4,616.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,896.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,806.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,986.37
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,661.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,693.34
|
| Rate for Payer: Ohio Health Group HMO |
$9,965.92
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,630.31
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,560.46
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,168.64
|
| Rate for Payer: PHCS Commercial |
$12,756.37
|
| Rate for Payer: United Healthcare All Payer |
$11,693.34
|
|
