|
SURGICEL SNOW 1X2 INCH
|
Facility
|
IP
|
$112.14
|
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.58 |
| Max. Negotiated Rate |
$107.65 |
| Rate for Payer: Aetna Commercial |
$86.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.47
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Cigna Commercial |
$93.08
|
| Rate for Payer: First Health Commercial |
$106.53
|
| Rate for Payer: Humana Commercial |
$95.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.68
|
| Rate for Payer: Ohio Health Group HMO |
$84.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.76
|
| Rate for Payer: PHCS Commercial |
$107.65
|
| Rate for Payer: United Healthcare All Payer |
$98.68
|
|
|
SURGICEL SNOW 1X2 INCH
|
Professional
|
Both
|
$112.14
|
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$39.25 |
| Max. Negotiated Rate |
$112.14 |
| Rate for Payer: Buckeye Medicare Advantage |
$112.14
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Multiplan PHCS |
$67.28
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$78.50
|
| Rate for Payer: UHCCP Medicaid |
$39.25
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
OP
|
$125.27
|
|
|
Service Code
|
NDC 63713002081
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$120.26 |
| Rate for Payer: Aetna Commercial |
$96.46
|
| Rate for Payer: Anthem Medicaid |
$43.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.71
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cigna Commercial |
$103.97
|
| Rate for Payer: First Health Commercial |
$119.01
|
| Rate for Payer: Humana Commercial |
$106.48
|
| Rate for Payer: Humana KY Medicaid |
$43.08
|
| Rate for Payer: Kentucky WC Medicaid |
$43.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.58
|
| Rate for Payer: Molina Healthcare Medicaid |
$43.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.24
|
| Rate for Payer: Ohio Health Group HMO |
$93.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.83
|
| Rate for Payer: PHCS Commercial |
$120.26
|
| Rate for Payer: United Healthcare All Payer |
$110.24
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
OP
|
$112.14
|
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.58 |
| Max. Negotiated Rate |
$107.65 |
| Rate for Payer: Aetna Commercial |
$86.35
|
| Rate for Payer: Anthem Medicaid |
$38.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.47
|
| Rate for Payer: Cash Price |
$56.07
|
| Rate for Payer: Cigna Commercial |
$93.08
|
| Rate for Payer: First Health Commercial |
$106.53
|
| Rate for Payer: Humana Commercial |
$95.32
|
| Rate for Payer: Humana KY Medicaid |
$38.56
|
| Rate for Payer: Kentucky WC Medicaid |
$38.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.64
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.68
|
| Rate for Payer: Ohio Health Group HMO |
$84.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.76
|
| Rate for Payer: PHCS Commercial |
$107.65
|
| Rate for Payer: United Healthcare All Payer |
$98.68
|
|
|
SURGICEL SNOW 1X2 INCH
|
Facility
|
IP
|
$125.27
|
|
|
Service Code
|
NDC 63713002081
|
| Hospital Charge Code |
27000229
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.29 |
| Max. Negotiated Rate |
$120.26 |
| Rate for Payer: Aetna Commercial |
$96.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$97.71
|
| Rate for Payer: Cash Price |
$62.63
|
| Rate for Payer: Cigna Commercial |
$103.97
|
| Rate for Payer: First Health Commercial |
$119.01
|
| Rate for Payer: Humana Commercial |
$106.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$102.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$92.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$37.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$110.24
|
| Rate for Payer: Ohio Health Group HMO |
$93.95
|
| Rate for Payer: Ohio Health Group PPO Differential |
$25.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$16.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$38.83
|
| Rate for Payer: PHCS Commercial |
$120.26
|
| Rate for Payer: United Healthcare All Payer |
$110.24
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
IP
|
$168.15
|
|
|
Service Code
|
NDC 63713002082
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$161.42 |
| Rate for Payer: Aetna Commercial |
$129.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.16
|
| Rate for Payer: Cash Price |
$84.08
|
| Rate for Payer: Cigna Commercial |
$139.56
|
| Rate for Payer: First Health Commercial |
$159.74
|
| Rate for Payer: Humana Commercial |
$142.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$147.97
|
| Rate for Payer: Ohio Health Group HMO |
$126.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.13
|
| Rate for Payer: PHCS Commercial |
$161.42
|
| Rate for Payer: United Healthcare All Payer |
$147.97
|
|
|
SURGICEL SNOW 2X4 INCH
|
Professional
|
Both
|
$158.17
|
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$55.36 |
| Max. Negotiated Rate |
$158.17 |
| Rate for Payer: Buckeye Medicare Advantage |
$158.17
|
| Rate for Payer: Cash Price |
$79.08
|
| Rate for Payer: Multiplan PHCS |
$94.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$110.72
|
| Rate for Payer: UHCCP Medicaid |
$55.36
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
OP
|
$158.17
|
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.56 |
| Max. Negotiated Rate |
$151.84 |
| Rate for Payer: Aetna Commercial |
$121.79
|
| Rate for Payer: Anthem Medicaid |
$54.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.37
|
| Rate for Payer: Cash Price |
$79.08
|
| Rate for Payer: Cigna Commercial |
$131.28
|
| Rate for Payer: First Health Commercial |
$150.26
|
| Rate for Payer: Humana Commercial |
$134.44
|
| Rate for Payer: Humana KY Medicaid |
$54.39
|
| Rate for Payer: Kentucky WC Medicaid |
$54.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$55.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.19
|
| Rate for Payer: Ohio Health Group HMO |
$118.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.03
|
| Rate for Payer: PHCS Commercial |
$151.84
|
| Rate for Payer: United Healthcare All Payer |
$139.19
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
IP
|
$158.17
|
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.56 |
| Max. Negotiated Rate |
$151.84 |
| Rate for Payer: Aetna Commercial |
$121.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$123.37
|
| Rate for Payer: Cash Price |
$79.08
|
| Rate for Payer: Cigna Commercial |
$131.28
|
| Rate for Payer: First Health Commercial |
$150.26
|
| Rate for Payer: Humana Commercial |
$134.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$129.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$116.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$47.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$139.19
|
| Rate for Payer: Ohio Health Group HMO |
$118.63
|
| Rate for Payer: Ohio Health Group PPO Differential |
$31.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.03
|
| Rate for Payer: PHCS Commercial |
$151.84
|
| Rate for Payer: United Healthcare All Payer |
$139.19
|
|
|
SURGICEL SNOW 2X4 INCH
|
Facility
|
OP
|
$168.15
|
|
|
Service Code
|
NDC 63713002082
|
| Hospital Charge Code |
27000228
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.86 |
| Max. Negotiated Rate |
$161.42 |
| Rate for Payer: Aetna Commercial |
$129.48
|
| Rate for Payer: Anthem Medicaid |
$57.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$131.16
|
| Rate for Payer: Cash Price |
$84.08
|
| Rate for Payer: Cigna Commercial |
$139.56
|
| Rate for Payer: First Health Commercial |
$159.74
|
| Rate for Payer: Humana Commercial |
$142.93
|
| Rate for Payer: Humana KY Medicaid |
$57.83
|
| Rate for Payer: Kentucky WC Medicaid |
$58.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$137.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$124.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$50.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$147.97
|
| Rate for Payer: Ohio Health Group HMO |
$126.11
|
| Rate for Payer: Ohio Health Group PPO Differential |
$33.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$21.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$52.13
|
| Rate for Payer: PHCS Commercial |
$161.42
|
| Rate for Payer: United Healthcare All Payer |
$147.97
|
|
|
SURGIFOAM 100CM 2 8 12.5CMSPNG
|
Facility
|
IP
|
$38.85
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
25003504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$37.30 |
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.30
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: Cigna Commercial |
$32.25
|
| Rate for Payer: First Health Commercial |
$36.91
|
| Rate for Payer: Humana Commercial |
$33.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.19
|
| Rate for Payer: Ohio Health Group HMO |
$29.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.04
|
| Rate for Payer: PHCS Commercial |
$37.30
|
| Rate for Payer: United Healthcare All Payer |
$34.19
|
|
|
SURGIFOAM 100CM 2 8 12.5CMSPNG
|
Facility
|
OP
|
$38.85
|
|
|
Service Code
|
NDC 63713001974
|
| Hospital Charge Code |
25003504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.05 |
| Max. Negotiated Rate |
$37.30 |
| Rate for Payer: Aetna Commercial |
$29.91
|
| Rate for Payer: Anthem Medicaid |
$13.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$30.30
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: Cigna Commercial |
$32.25
|
| Rate for Payer: First Health Commercial |
$36.91
|
| Rate for Payer: Humana Commercial |
$33.02
|
| Rate for Payer: Humana KY Medicaid |
$13.36
|
| Rate for Payer: Kentucky WC Medicaid |
$13.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$31.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$28.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$11.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$34.19
|
| Rate for Payer: Ohio Health Group HMO |
$29.14
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$12.04
|
| Rate for Payer: PHCS Commercial |
$37.30
|
| Rate for Payer: United Healthcare All Payer |
$34.19
|
|
|
SURGIFOAM 50CM^2 8*6.25CM SPNG
|
Facility
|
OP
|
$30.96
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
25003747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$29.72 |
| Rate for Payer: Aetna Commercial |
$23.84
|
| Rate for Payer: Anthem Medicaid |
$10.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.15
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cigna Commercial |
$25.70
|
| Rate for Payer: First Health Commercial |
$29.41
|
| Rate for Payer: Humana Commercial |
$26.32
|
| Rate for Payer: Humana KY Medicaid |
$10.65
|
| Rate for Payer: Kentucky WC Medicaid |
$10.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.24
|
| Rate for Payer: Ohio Health Group HMO |
$23.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.60
|
| Rate for Payer: PHCS Commercial |
$29.72
|
| Rate for Payer: United Healthcare All Payer |
$27.24
|
|
|
SURGIFOAM 50CM^2 8*6.25CM SPNG
|
Facility
|
IP
|
$30.96
|
|
|
Service Code
|
NDC 63713001972
|
| Hospital Charge Code |
25003747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.02 |
| Max. Negotiated Rate |
$29.72 |
| Rate for Payer: Aetna Commercial |
$23.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$24.15
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cigna Commercial |
$25.70
|
| Rate for Payer: First Health Commercial |
$29.41
|
| Rate for Payer: Humana Commercial |
$26.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$25.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22.85
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$9.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$27.24
|
| Rate for Payer: Ohio Health Group HMO |
$23.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.19
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9.60
|
| Rate for Payer: PHCS Commercial |
$29.72
|
| Rate for Payer: United Healthcare All Payer |
$27.24
|
|
|
SURGIMEND COLLAGEN MATRIX 25*4
|
Facility
|
IP
|
$90,700.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,791.00 |
| Max. Negotiated Rate |
$87,072.00 |
| Rate for Payer: Aetna Commercial |
$69,839.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70,746.00
|
| Rate for Payer: Cash Price |
$45,350.00
|
| Rate for Payer: Cigna Commercial |
$75,281.00
|
| Rate for Payer: First Health Commercial |
$86,165.00
|
| Rate for Payer: Humana Commercial |
$77,095.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74,374.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66,936.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27,210.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$79,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$68,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,791.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,117.00
|
| Rate for Payer: PHCS Commercial |
$87,072.00
|
| Rate for Payer: United Healthcare All Payer |
$79,816.00
|
|
|
SURGIMEND COLLAGEN MATRIX 25*4
|
Facility
|
OP
|
$90,700.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$11,791.00 |
| Max. Negotiated Rate |
$87,072.00 |
| Rate for Payer: Aetna Commercial |
$69,839.00
|
| Rate for Payer: Anthem Medicaid |
$31,191.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$70,746.00
|
| Rate for Payer: Cash Price |
$45,350.00
|
| Rate for Payer: Cigna Commercial |
$75,281.00
|
| Rate for Payer: First Health Commercial |
$86,165.00
|
| Rate for Payer: Humana Commercial |
$77,095.00
|
| Rate for Payer: Humana KY Medicaid |
$31,191.73
|
| Rate for Payer: Kentucky WC Medicaid |
$31,509.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$74,374.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$66,936.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$27,210.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$31,817.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$79,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$68,025.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18,140.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,791.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$28,117.00
|
| Rate for Payer: PHCS Commercial |
$87,072.00
|
| Rate for Payer: United Healthcare All Payer |
$79,816.00
|
|
|
SURGIMEND MP MESH 10CM*15CM*2M
|
Facility
|
IP
|
$15,000.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$14,400.00 |
| Rate for Payer: Aetna Commercial |
$11,550.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,700.00
|
| Rate for Payer: Cash Price |
$7,500.00
|
| Rate for Payer: Cigna Commercial |
$12,450.00
|
| Rate for Payer: First Health Commercial |
$14,250.00
|
| Rate for Payer: Humana Commercial |
$12,750.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,300.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,070.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,500.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,650.00
|
| Rate for Payer: PHCS Commercial |
$14,400.00
|
| Rate for Payer: United Healthcare All Payer |
$13,200.00
|
|
|
SURGIMEND MP MESH 10CM*15CM*2M
|
Facility
|
OP
|
$15,000.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,950.00 |
| Max. Negotiated Rate |
$14,400.00 |
| Rate for Payer: Aetna Commercial |
$11,550.00
|
| Rate for Payer: Anthem Medicaid |
$5,158.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,700.00
|
| Rate for Payer: Cash Price |
$7,500.00
|
| Rate for Payer: Cigna Commercial |
$12,450.00
|
| Rate for Payer: First Health Commercial |
$14,250.00
|
| Rate for Payer: Humana Commercial |
$12,750.00
|
| Rate for Payer: Humana KY Medicaid |
$5,158.50
|
| Rate for Payer: Kentucky WC Medicaid |
$5,211.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,300.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,070.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,500.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,262.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$11,250.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,950.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,650.00
|
| Rate for Payer: PHCS Commercial |
$14,400.00
|
| Rate for Payer: United Healthcare All Payer |
$13,200.00
|
|
|
SURGIMEND MP MESH 16CM*20CM*2M
|
Facility
|
IP
|
$22,320.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,901.60 |
| Max. Negotiated Rate |
$21,427.20 |
| Rate for Payer: Aetna Commercial |
$17,186.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,409.60
|
| Rate for Payer: Cash Price |
$11,160.00
|
| Rate for Payer: Cigna Commercial |
$18,525.60
|
| Rate for Payer: First Health Commercial |
$21,204.00
|
| Rate for Payer: Humana Commercial |
$18,972.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,302.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,472.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,696.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,641.60
|
| Rate for Payer: Ohio Health Group HMO |
$16,740.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,919.20
|
| Rate for Payer: PHCS Commercial |
$21,427.20
|
| Rate for Payer: United Healthcare All Payer |
$19,641.60
|
|
|
SURGIMEND MP MESH 16CM*20CM*2M
|
Facility
|
OP
|
$22,320.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,901.60 |
| Max. Negotiated Rate |
$21,427.20 |
| Rate for Payer: Aetna Commercial |
$17,186.40
|
| Rate for Payer: Anthem Medicaid |
$7,675.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,409.60
|
| Rate for Payer: Cash Price |
$11,160.00
|
| Rate for Payer: Cigna Commercial |
$18,525.60
|
| Rate for Payer: First Health Commercial |
$21,204.00
|
| Rate for Payer: Humana Commercial |
$18,972.00
|
| Rate for Payer: Humana KY Medicaid |
$7,675.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,753.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,302.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,472.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,696.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,829.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,641.60
|
| Rate for Payer: Ohio Health Group HMO |
$16,740.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,464.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,901.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,919.20
|
| Rate for Payer: PHCS Commercial |
$21,427.20
|
| Rate for Payer: United Healthcare All Payer |
$19,641.60
|
|
|
SURGIMEND PRS MESH 10CM*15CM
|
Facility
|
OP
|
$16,620.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.60 |
| Max. Negotiated Rate |
$15,955.20 |
| Rate for Payer: Aetna Commercial |
$12,797.40
|
| Rate for Payer: Anthem Medicaid |
$5,715.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,963.60
|
| Rate for Payer: Cash Price |
$8,310.00
|
| Rate for Payer: Cigna Commercial |
$13,794.60
|
| Rate for Payer: First Health Commercial |
$15,789.00
|
| Rate for Payer: Humana Commercial |
$14,127.00
|
| Rate for Payer: Humana KY Medicaid |
$5,715.62
|
| Rate for Payer: Kentucky WC Medicaid |
$5,773.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,628.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,265.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,986.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,830.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,625.60
|
| Rate for Payer: Ohio Health Group HMO |
$12,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,324.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,152.20
|
| Rate for Payer: PHCS Commercial |
$15,955.20
|
| Rate for Payer: United Healthcare All Payer |
$14,625.60
|
|
|
SURGIMEND PRS MESH 10CM*15CM
|
Facility
|
IP
|
$16,620.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.60 |
| Max. Negotiated Rate |
$15,955.20 |
| Rate for Payer: Aetna Commercial |
$12,797.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,963.60
|
| Rate for Payer: Cash Price |
$8,310.00
|
| Rate for Payer: Cigna Commercial |
$13,794.60
|
| Rate for Payer: First Health Commercial |
$15,789.00
|
| Rate for Payer: Humana Commercial |
$14,127.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,628.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,265.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,986.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,625.60
|
| Rate for Payer: Ohio Health Group HMO |
$12,465.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,324.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,160.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,152.20
|
| Rate for Payer: PHCS Commercial |
$15,955.20
|
| Rate for Payer: United Healthcare All Payer |
$14,625.60
|
|
|
SURGIMEND PRS MESH 20CM*10CM
|
Facility
|
OP
|
$29,985.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,898.05 |
| Max. Negotiated Rate |
$28,785.60 |
| Rate for Payer: Aetna Commercial |
$23,088.45
|
| Rate for Payer: Anthem Medicaid |
$10,311.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,388.30
|
| Rate for Payer: Cash Price |
$14,992.50
|
| Rate for Payer: Cigna Commercial |
$24,887.55
|
| Rate for Payer: First Health Commercial |
$28,485.75
|
| Rate for Payer: Humana Commercial |
$25,487.25
|
| Rate for Payer: Humana KY Medicaid |
$10,311.84
|
| Rate for Payer: Kentucky WC Medicaid |
$10,416.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,587.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,128.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,995.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$10,518.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,386.80
|
| Rate for Payer: Ohio Health Group HMO |
$22,488.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,997.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,898.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,295.35
|
| Rate for Payer: PHCS Commercial |
$28,785.60
|
| Rate for Payer: United Healthcare All Payer |
$26,386.80
|
|
|
SURGIMEND PRS MESH 20CM*10CM
|
Facility
|
IP
|
$29,985.00
|
|
|
Service Code
|
HCPCS C9358
|
| Hospital Charge Code |
27000074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,898.05 |
| Max. Negotiated Rate |
$28,785.60 |
| Rate for Payer: Aetna Commercial |
$23,088.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$23,388.30
|
| Rate for Payer: Cash Price |
$14,992.50
|
| Rate for Payer: Cigna Commercial |
$24,887.55
|
| Rate for Payer: First Health Commercial |
$28,485.75
|
| Rate for Payer: Humana Commercial |
$25,487.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$24,587.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$22,128.93
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,995.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$26,386.80
|
| Rate for Payer: Ohio Health Group HMO |
$22,488.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,997.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,898.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,295.35
|
| Rate for Payer: PHCS Commercial |
$28,785.60
|
| Rate for Payer: United Healthcare All Payer |
$26,386.80
|
|
|
SURG STEEL MONO SUTURE 18*5
|
Facility
|
OP
|
$1,161.66
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$151.02 |
| Max. Negotiated Rate |
$1,115.19 |
| Rate for Payer: Aetna Commercial |
$894.48
|
| Rate for Payer: Anthem Medicaid |
$399.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$906.09
|
| Rate for Payer: Cash Price |
$580.83
|
| Rate for Payer: Cigna Commercial |
$964.18
|
| Rate for Payer: First Health Commercial |
$1,103.58
|
| Rate for Payer: Humana Commercial |
$987.41
|
| Rate for Payer: Humana KY Medicaid |
$399.49
|
| Rate for Payer: Kentucky WC Medicaid |
$403.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$952.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$857.31
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$348.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$407.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,022.26
|
| Rate for Payer: Ohio Health Group HMO |
$871.24
|
| Rate for Payer: Ohio Health Group PPO Differential |
$232.33
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$151.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$360.11
|
| Rate for Payer: PHCS Commercial |
$1,115.19
|
| Rate for Payer: United Healthcare All Payer |
$1,022.26
|
|
