|
R3 20DEG XLPE ACET LNR 36*54M
|
Facility
|
OP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem Medicaid |
$3,375.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Humana KY Medicaid |
$3,375.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,410.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,443.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*54M
|
Facility
|
IP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*58M
|
Facility
|
IP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*58M
|
Facility
|
OP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem Medicaid |
$3,375.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Humana KY Medicaid |
$3,375.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,410.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,443.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*60M
|
Facility
|
OP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem Medicaid |
$3,375.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Humana KY Medicaid |
$3,375.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,410.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,443.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*60M
|
Facility
|
IP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*62M
|
Facility
|
IP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*62M
|
Facility
|
OP
|
$9,816.19
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,944.86 |
| Max. Negotiated Rate |
$9,423.54 |
| Rate for Payer: Aetna Commercial |
$7,558.47
|
| Rate for Payer: Anthem Medicaid |
$3,375.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,656.63
|
| Rate for Payer: Cash Price |
$4,908.10
|
| Rate for Payer: Cigna Commercial |
$8,147.44
|
| Rate for Payer: First Health Commercial |
$9,325.38
|
| Rate for Payer: Humana Commercial |
$8,343.76
|
| Rate for Payer: Humana KY Medicaid |
$3,375.79
|
| Rate for Payer: Kentucky WC Medicaid |
$3,410.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,049.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,244.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,944.86
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,443.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,638.25
|
| Rate for Payer: Ohio Health Group HMO |
$7,362.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,852.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,540.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,773.17
|
| Rate for Payer: PHCS Commercial |
$9,423.54
|
| Rate for Payer: United Healthcare All Payer |
$8,638.25
|
|
|
R3 20DEG XLPE ACET LNR 36*64M
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEG XLPE ACET LNR 36*64M
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEGXLPE ACT LNR 36*66/68M
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20DEGXLPE ACT LNR 36*66/68M
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*46
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*46
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*48
|
Facility
|
OP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem Medicaid |
$1,719.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Humana KY Medicaid |
$1,719.50
|
| Rate for Payer: Kentucky WC Medicaid |
$1,737.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,754.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20 XLPE ACET LINER 28*48
|
Facility
|
IP
|
$5,000.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.00 |
| Max. Negotiated Rate |
$4,800.00 |
| Rate for Payer: Aetna Commercial |
$3,850.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,900.00
|
| Rate for Payer: Cash Price |
$2,500.00
|
| Rate for Payer: Cigna Commercial |
$4,150.00
|
| Rate for Payer: First Health Commercial |
$4,750.00
|
| Rate for Payer: Humana Commercial |
$4,250.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,100.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,690.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,400.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,750.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,350.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,450.00
|
| Rate for Payer: PHCS Commercial |
$4,800.00
|
| Rate for Payer: United Healthcare All Payer |
$4,400.00
|
|
|
R3 20^ XLPE ACET LINER 32*48
|
Facility
|
OP
|
$17,590.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,277.15 |
| Max. Negotiated Rate |
$16,886.88 |
| Rate for Payer: Aetna Commercial |
$13,544.68
|
| Rate for Payer: Anthem Medicaid |
$6,049.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,720.59
|
| Rate for Payer: Cash Price |
$8,795.25
|
| Rate for Payer: Cigna Commercial |
$14,600.11
|
| Rate for Payer: First Health Commercial |
$16,710.97
|
| Rate for Payer: Humana Commercial |
$14,951.92
|
| Rate for Payer: Humana KY Medicaid |
$6,049.37
|
| Rate for Payer: Kentucky WC Medicaid |
$6,110.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,424.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,981.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,277.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,170.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,479.64
|
| Rate for Payer: Ohio Health Group HMO |
$13,192.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,072.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,303.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,137.44
|
| Rate for Payer: PHCS Commercial |
$16,886.88
|
| Rate for Payer: United Healthcare All Payer |
$15,479.64
|
|
|
R3 20^ XLPE ACET LINER 32*48
|
Facility
|
IP
|
$17,590.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,277.15 |
| Max. Negotiated Rate |
$16,886.88 |
| Rate for Payer: Aetna Commercial |
$13,544.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,720.59
|
| Rate for Payer: Cash Price |
$8,795.25
|
| Rate for Payer: Cigna Commercial |
$14,600.11
|
| Rate for Payer: First Health Commercial |
$16,710.97
|
| Rate for Payer: Humana Commercial |
$14,951.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$14,424.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,981.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,277.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$15,479.64
|
| Rate for Payer: Ohio Health Group HMO |
$13,192.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$14,072.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15,303.74
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12,137.44
|
| Rate for Payer: PHCS Commercial |
$16,886.88
|
| Rate for Payer: United Healthcare All Payer |
$15,479.64
|
|
|
R3 3H HA CTD ACET SHELL 40MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 40MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 42MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 42MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 44MM
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 44MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
R3 3H HA CTD ACET SHELL 46MM
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
