|
PRIMATRIX 3*3
|
Facility
|
IP
|
$4,177.50
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$543.08 |
| Max. Negotiated Rate |
$4,010.40 |
| Rate for Payer: Aetna Commercial |
$3,216.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,258.45
|
| Rate for Payer: Cash Price |
$2,088.75
|
| Rate for Payer: Cigna Commercial |
$3,467.32
|
| Rate for Payer: First Health Commercial |
$3,968.62
|
| Rate for Payer: Humana Commercial |
$3,550.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,425.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,083.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,253.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,676.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,133.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$835.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.02
|
| Rate for Payer: PHCS Commercial |
$4,010.40
|
| Rate for Payer: United Healthcare All Payer |
$3,676.20
|
|
|
PRIMATRIX 3*3
|
Facility
|
OP
|
$4,177.50
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$543.08 |
| Max. Negotiated Rate |
$4,010.40 |
| Rate for Payer: Aetna Commercial |
$3,216.68
|
| Rate for Payer: Anthem Medicaid |
$1,436.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,258.45
|
| Rate for Payer: Cash Price |
$2,088.75
|
| Rate for Payer: Cigna Commercial |
$3,467.32
|
| Rate for Payer: First Health Commercial |
$3,968.62
|
| Rate for Payer: Humana Commercial |
$3,550.88
|
| Rate for Payer: Humana KY Medicaid |
$1,436.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1,451.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,425.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,083.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,253.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,465.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,676.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,133.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$835.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$543.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,295.02
|
| Rate for Payer: PHCS Commercial |
$4,010.40
|
| Rate for Payer: United Healthcare All Payer |
$3,676.20
|
|
|
PRIMATRIX 4*4CM FENESTRATED
|
Facility
|
IP
|
$4,492.50
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$584.02 |
| Max. Negotiated Rate |
$4,312.80 |
| Rate for Payer: Aetna Commercial |
$3,459.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,504.15
|
| Rate for Payer: Cash Price |
$2,246.25
|
| Rate for Payer: Cigna Commercial |
$3,728.78
|
| Rate for Payer: First Health Commercial |
$4,267.88
|
| Rate for Payer: Humana Commercial |
$3,818.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,683.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,315.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,347.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,953.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,369.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$898.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$584.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,392.68
|
| Rate for Payer: PHCS Commercial |
$4,312.80
|
| Rate for Payer: United Healthcare All Payer |
$3,953.40
|
|
|
PRIMATRIX 4*4CM FENESTRATED
|
Facility
|
OP
|
$4,492.50
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$584.02 |
| Max. Negotiated Rate |
$4,312.80 |
| Rate for Payer: Aetna Commercial |
$3,459.22
|
| Rate for Payer: Anthem Medicaid |
$1,544.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,504.15
|
| Rate for Payer: Cash Price |
$2,246.25
|
| Rate for Payer: Cigna Commercial |
$3,728.78
|
| Rate for Payer: First Health Commercial |
$4,267.88
|
| Rate for Payer: Humana Commercial |
$3,818.62
|
| Rate for Payer: Humana KY Medicaid |
$1,544.97
|
| Rate for Payer: Kentucky WC Medicaid |
$1,560.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,683.85
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,315.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,347.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,575.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,953.40
|
| Rate for Payer: Ohio Health Group HMO |
$3,369.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$898.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$584.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,392.68
|
| Rate for Payer: PHCS Commercial |
$4,312.80
|
| Rate for Payer: United Healthcare All Payer |
$3,953.40
|
|
|
PRIMATRIX 4*4CM MESHED
|
Facility
|
OP
|
$4,979.70
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$647.36 |
| Max. Negotiated Rate |
$4,780.51 |
| Rate for Payer: Aetna Commercial |
$3,834.37
|
| Rate for Payer: Anthem Medicaid |
$1,712.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,884.17
|
| Rate for Payer: Cash Price |
$2,489.85
|
| Rate for Payer: Cigna Commercial |
$4,133.15
|
| Rate for Payer: First Health Commercial |
$4,730.72
|
| Rate for Payer: Humana Commercial |
$4,232.74
|
| Rate for Payer: Humana KY Medicaid |
$1,712.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1,729.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,083.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,675.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,493.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,746.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,382.14
|
| Rate for Payer: Ohio Health Group HMO |
$3,734.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$995.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,543.71
|
| Rate for Payer: PHCS Commercial |
$4,780.51
|
| Rate for Payer: United Healthcare All Payer |
$4,382.14
|
|
|
PRIMATRIX 4*4CM MESHED
|
Facility
|
IP
|
$4,979.70
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$647.36 |
| Max. Negotiated Rate |
$4,780.51 |
| Rate for Payer: Aetna Commercial |
$3,834.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,884.17
|
| Rate for Payer: Cash Price |
$2,489.85
|
| Rate for Payer: Cigna Commercial |
$4,133.15
|
| Rate for Payer: First Health Commercial |
$4,730.72
|
| Rate for Payer: Humana Commercial |
$4,232.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,083.35
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,675.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,493.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,382.14
|
| Rate for Payer: Ohio Health Group HMO |
$3,734.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$995.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$647.36
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,543.71
|
| Rate for Payer: PHCS Commercial |
$4,780.51
|
| Rate for Payer: United Healthcare All Payer |
$4,382.14
|
|
|
PRIMATRIX 6*6CM FENESTRATED
|
Facility
|
OP
|
$7,916.35
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,029.13 |
| Max. Negotiated Rate |
$7,599.70 |
| Rate for Payer: Aetna Commercial |
$6,095.59
|
| Rate for Payer: Anthem Medicaid |
$2,722.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,174.75
|
| Rate for Payer: Cash Price |
$3,958.18
|
| Rate for Payer: Cigna Commercial |
$6,570.57
|
| Rate for Payer: First Health Commercial |
$7,520.53
|
| Rate for Payer: Humana Commercial |
$6,728.90
|
| Rate for Payer: Humana KY Medicaid |
$2,722.43
|
| Rate for Payer: Kentucky WC Medicaid |
$2,750.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,491.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,842.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,374.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,777.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,966.39
|
| Rate for Payer: Ohio Health Group HMO |
$5,937.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,583.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,029.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,454.07
|
| Rate for Payer: PHCS Commercial |
$7,599.70
|
| Rate for Payer: United Healthcare All Payer |
$6,966.39
|
|
|
PRIMATRIX 6*6CM FENESTRATED
|
Facility
|
IP
|
$7,916.35
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,029.13 |
| Max. Negotiated Rate |
$7,599.70 |
| Rate for Payer: Aetna Commercial |
$6,095.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,174.75
|
| Rate for Payer: Cash Price |
$3,958.18
|
| Rate for Payer: Cigna Commercial |
$6,570.57
|
| Rate for Payer: First Health Commercial |
$7,520.53
|
| Rate for Payer: Humana Commercial |
$6,728.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,491.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,842.27
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,374.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,966.39
|
| Rate for Payer: Ohio Health Group HMO |
$5,937.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,583.27
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,029.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,454.07
|
| Rate for Payer: PHCS Commercial |
$7,599.70
|
| Rate for Payer: United Healthcare All Payer |
$6,966.39
|
|
|
PRIMATRIX 6*6CM MESHED
|
Facility
|
IP
|
$10,965.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
PRIMATRIX 6*6CM MESHED
|
Facility
|
OP
|
$10,965.00
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,425.45 |
| Max. Negotiated Rate |
$10,526.40 |
| Rate for Payer: Aetna Commercial |
$8,443.05
|
| Rate for Payer: Anthem Medicaid |
$3,770.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,552.70
|
| Rate for Payer: Cash Price |
$5,482.50
|
| Rate for Payer: Cigna Commercial |
$9,100.95
|
| Rate for Payer: First Health Commercial |
$10,416.75
|
| Rate for Payer: Humana Commercial |
$9,320.25
|
| Rate for Payer: Humana KY Medicaid |
$3,770.86
|
| Rate for Payer: Kentucky WC Medicaid |
$3,809.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,991.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,092.17
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,289.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,846.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,649.20
|
| Rate for Payer: Ohio Health Group HMO |
$8,223.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,193.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,425.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,399.15
|
| Rate for Payer: PHCS Commercial |
$10,526.40
|
| Rate for Payer: United Healthcare All Payer |
$9,649.20
|
|
|
PRIMATRIX 8*8CM FENESTRATED
|
Facility
|
OP
|
$11,242.40
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,461.51 |
| Max. Negotiated Rate |
$10,792.70 |
| Rate for Payer: Aetna Commercial |
$8,656.65
|
| Rate for Payer: Anthem Medicaid |
$3,866.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,769.07
|
| Rate for Payer: Cash Price |
$5,621.20
|
| Rate for Payer: Cigna Commercial |
$9,331.19
|
| Rate for Payer: First Health Commercial |
$10,680.28
|
| Rate for Payer: Humana Commercial |
$9,556.04
|
| Rate for Payer: Humana KY Medicaid |
$3,866.26
|
| Rate for Payer: Kentucky WC Medicaid |
$3,905.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,218.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,296.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,372.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,943.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,893.31
|
| Rate for Payer: Ohio Health Group HMO |
$8,431.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,248.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,485.14
|
| Rate for Payer: PHCS Commercial |
$10,792.70
|
| Rate for Payer: United Healthcare All Payer |
$9,893.31
|
|
|
PRIMATRIX 8*8CM FENESTRATED
|
Facility
|
IP
|
$11,242.40
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,461.51 |
| Max. Negotiated Rate |
$10,792.70 |
| Rate for Payer: Aetna Commercial |
$8,656.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,769.07
|
| Rate for Payer: Cash Price |
$5,621.20
|
| Rate for Payer: Cigna Commercial |
$9,331.19
|
| Rate for Payer: First Health Commercial |
$10,680.28
|
| Rate for Payer: Humana Commercial |
$9,556.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,218.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,296.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,372.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,893.31
|
| Rate for Payer: Ohio Health Group HMO |
$8,431.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,248.48
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,461.51
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,485.14
|
| Rate for Payer: PHCS Commercial |
$10,792.70
|
| Rate for Payer: United Healthcare All Payer |
$9,893.31
|
|
|
PRIMATRIX AG 4*4CM FENESTRATED
|
Facility
|
OP
|
$4,293.28
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$558.13 |
| Max. Negotiated Rate |
$4,121.55 |
| Rate for Payer: Aetna Commercial |
$3,305.83
|
| Rate for Payer: Anthem Medicaid |
$1,476.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.76
|
| Rate for Payer: Cash Price |
$2,146.64
|
| Rate for Payer: Cigna Commercial |
$3,563.42
|
| Rate for Payer: First Health Commercial |
$4,078.62
|
| Rate for Payer: Humana Commercial |
$3,649.29
|
| Rate for Payer: Humana KY Medicaid |
$1,476.46
|
| Rate for Payer: Kentucky WC Medicaid |
$1,491.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,520.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,168.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,287.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,506.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,778.09
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$858.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$558.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,330.92
|
| Rate for Payer: PHCS Commercial |
$4,121.55
|
| Rate for Payer: United Healthcare All Payer |
$3,778.09
|
|
|
PRIMATRIX AG 4*4CM FENESTRATED
|
Facility
|
IP
|
$4,293.28
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$558.13 |
| Max. Negotiated Rate |
$4,121.55 |
| Rate for Payer: Aetna Commercial |
$3,305.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,348.76
|
| Rate for Payer: Cash Price |
$2,146.64
|
| Rate for Payer: Cigna Commercial |
$3,563.42
|
| Rate for Payer: First Health Commercial |
$4,078.62
|
| Rate for Payer: Humana Commercial |
$3,649.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,520.49
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,168.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,287.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,778.09
|
| Rate for Payer: Ohio Health Group HMO |
$3,219.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$858.66
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$558.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,330.92
|
| Rate for Payer: PHCS Commercial |
$4,121.55
|
| Rate for Payer: United Healthcare All Payer |
$3,778.09
|
|
|
PRIMATRIX AG 4*4CM MESHED
|
Facility
|
IP
|
$4,212.50
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$547.62 |
| Max. Negotiated Rate |
$4,044.00 |
| Rate for Payer: Aetna Commercial |
$3,243.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,285.75
|
| Rate for Payer: Cash Price |
$2,106.25
|
| Rate for Payer: Cigna Commercial |
$3,496.38
|
| Rate for Payer: First Health Commercial |
$4,001.88
|
| Rate for Payer: Humana Commercial |
$3,580.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,454.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,108.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,263.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,707.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,159.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$842.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,305.88
|
| Rate for Payer: PHCS Commercial |
$4,044.00
|
| Rate for Payer: United Healthcare All Payer |
$3,707.00
|
|
|
PRIMATRIX AG 4*4CM MESHED
|
Facility
|
OP
|
$4,212.50
|
|
|
Service Code
|
HCPCS Q4110
|
| Hospital Charge Code |
27000119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$547.62 |
| Max. Negotiated Rate |
$4,044.00 |
| Rate for Payer: Aetna Commercial |
$3,243.62
|
| Rate for Payer: Anthem Medicaid |
$1,448.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,285.75
|
| Rate for Payer: Cash Price |
$2,106.25
|
| Rate for Payer: Cigna Commercial |
$3,496.38
|
| Rate for Payer: First Health Commercial |
$4,001.88
|
| Rate for Payer: Humana Commercial |
$3,580.62
|
| Rate for Payer: Humana KY Medicaid |
$1,448.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1,463.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,454.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,108.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,263.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,477.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,707.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,159.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$842.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,305.88
|
| Rate for Payer: PHCS Commercial |
$4,044.00
|
| Rate for Payer: United Healthcare All Payer |
$3,707.00
|
|
|
PRIMAXIN (IMIPENEM- 500MG/10ML
|
Facility
|
IP
|
$188.65
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
25001963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.52 |
| Max. Negotiated Rate |
$181.10 |
| Rate for Payer: Aetna Commercial |
$145.26
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.15
|
| Rate for Payer: Cash Price |
$94.33
|
| Rate for Payer: Cigna Commercial |
$156.58
|
| Rate for Payer: First Health Commercial |
$179.22
|
| Rate for Payer: Humana Commercial |
$160.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.01
|
| Rate for Payer: Ohio Health Group HMO |
$141.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.48
|
| Rate for Payer: PHCS Commercial |
$181.10
|
| Rate for Payer: United Healthcare All Payer |
$166.01
|
|
|
PRIMAXIN (IMIPENEM- 500MG/10ML
|
Facility
|
OP
|
$188.65
|
|
|
Service Code
|
HCPCS J0743
|
| Hospital Charge Code |
25001963
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.52 |
| Max. Negotiated Rate |
$181.10 |
| Rate for Payer: Aetna Commercial |
$145.26
|
| Rate for Payer: Anthem Medicaid |
$64.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$147.15
|
| Rate for Payer: Cash Price |
$94.33
|
| Rate for Payer: Cigna Commercial |
$156.58
|
| Rate for Payer: First Health Commercial |
$179.22
|
| Rate for Payer: Humana Commercial |
$160.35
|
| Rate for Payer: Humana KY Medicaid |
$64.88
|
| Rate for Payer: Kentucky WC Medicaid |
$65.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$154.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$139.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$56.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$66.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$166.01
|
| Rate for Payer: Ohio Health Group HMO |
$141.49
|
| Rate for Payer: Ohio Health Group PPO Differential |
$37.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$58.48
|
| Rate for Payer: PHCS Commercial |
$181.10
|
| Rate for Payer: United Healthcare All Payer |
$166.01
|
|
|
PRIM CPCS COCR HO 12/14 SZ 0
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
PRIM CPCS COCR HO 12/14 SZ 0
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
PRIM CPCS COCR HO 12/14 SZ 1
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
PRIM CPCS COCR HO 12/14 SZ 1
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
PRIM CPCS COCR HO 12/14 SZ 2
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
PRIM CPCS COCR HO 12/14 SZ 2
|
Facility
|
OP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem Medicaid |
$2,845.77
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Humana KY Medicaid |
$2,845.77
|
| Rate for Payer: Kentucky WC Medicaid |
$2,874.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,902.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
|
PRIM CPCS COCR HO 12/14 SZ 3
|
Facility
|
IP
|
$8,275.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,075.75 |
| Max. Negotiated Rate |
$7,944.00 |
| Rate for Payer: Aetna Commercial |
$6,371.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,454.50
|
| Rate for Payer: Cash Price |
$4,137.50
|
| Rate for Payer: Cigna Commercial |
$6,868.25
|
| Rate for Payer: First Health Commercial |
$7,861.25
|
| Rate for Payer: Humana Commercial |
$7,033.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,785.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,106.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,482.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,282.00
|
| Rate for Payer: Ohio Health Group HMO |
$6,206.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,655.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,075.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,565.25
|
| Rate for Payer: PHCS Commercial |
$7,944.00
|
| Rate for Payer: United Healthcare All Payer |
$7,282.00
|
|
