|
FORTRESS DEST SHTH ST 6F 45CM
|
Facility
|
OP
|
$3,687.50
|
|
|
Service Code
|
HCPCS C1894
|
| Hospital Charge Code |
27000113
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,106.25 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,950.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,208.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,544.38
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
FOSAMAX (ALENDRONATE 10MG/1TAB
|
Facility
|
OP
|
$4.34
|
|
|
Service Code
|
NDC 64980034001
|
| Hospital Charge Code |
25000703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem Medicaid |
$1.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Humana KY Medicaid |
$1.49
|
| Rate for Payer: Kentucky WC Medicaid |
$1.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
FOSAMAX (ALENDRONATE 10MG/1TAB
|
Facility
|
IP
|
$4.34
|
|
|
Service Code
|
NDC 64980034001
|
| Hospital Charge Code |
25000703
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.39
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cigna Commercial |
$3.60
|
| Rate for Payer: First Health Commercial |
$4.12
|
| Rate for Payer: Humana Commercial |
$3.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.82
|
| Rate for Payer: Ohio Health Group HMO |
$3.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.47
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.78
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.99
|
| Rate for Payer: PHCS Commercial |
$4.17
|
| Rate for Payer: United Healthcare All Payer |
$3.82
|
|
|
FOSAMAX (ALENDRON SOD)70MG TAB
|
Facility
|
IP
|
$4.83
|
|
|
Service Code
|
NDC 64980034214
|
| Hospital Charge Code |
25000702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.01
|
| Rate for Payer: First Health Commercial |
$4.59
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.25
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Payer |
$4.25
|
|
|
FOSAMAX (ALENDRON SOD)70MG TAB
|
Facility
|
OP
|
$4.83
|
|
|
Service Code
|
NDC 64980034214
|
| Hospital Charge Code |
25000702
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$4.64 |
| Rate for Payer: Aetna Commercial |
$3.72
|
| Rate for Payer: Anthem Medicaid |
$1.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.77
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.01
|
| Rate for Payer: First Health Commercial |
$4.59
|
| Rate for Payer: Humana Commercial |
$4.11
|
| Rate for Payer: Humana KY Medicaid |
$1.66
|
| Rate for Payer: Kentucky WC Medicaid |
$1.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.69
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.25
|
| Rate for Payer: Ohio Health Group HMO |
$3.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.33
|
| Rate for Payer: PHCS Commercial |
$4.64
|
| Rate for Payer: United Healthcare All Payer |
$4.25
|
|
|
FOSRENOL (5mg)500MG CHEW
|
Facility
|
IP
|
$29.01
|
|
|
Service Code
|
HCPCS J0607
|
| Hospital Charge Code |
25000704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Aetna Commercial |
$22.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.63
|
| Rate for Payer: Cash Price |
$14.51
|
| Rate for Payer: Cigna Commercial |
$24.08
|
| Rate for Payer: First Health Commercial |
$27.56
|
| Rate for Payer: Humana Commercial |
$24.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.53
|
| Rate for Payer: Ohio Health Group HMO |
$21.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.02
|
| Rate for Payer: PHCS Commercial |
$27.85
|
| Rate for Payer: United Healthcare All Payer |
$25.53
|
|
|
FOSRENOL (5mg)500MG CHEW
|
Facility
|
OP
|
$29.01
|
|
|
Service Code
|
HCPCS J0607
|
| Hospital Charge Code |
25000704
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.70 |
| Max. Negotiated Rate |
$27.85 |
| Rate for Payer: Aetna Commercial |
$22.34
|
| Rate for Payer: Anthem Medicaid |
$9.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.63
|
| Rate for Payer: Cash Price |
$14.51
|
| Rate for Payer: Cigna Commercial |
$24.08
|
| Rate for Payer: First Health Commercial |
$27.56
|
| Rate for Payer: Humana Commercial |
$24.66
|
| Rate for Payer: Humana KY Medicaid |
$9.98
|
| Rate for Payer: Kentucky WC Medicaid |
$10.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$21.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$10.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.53
|
| Rate for Payer: Ohio Health Group HMO |
$21.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.21
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$25.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$20.02
|
| Rate for Payer: PHCS Commercial |
$27.85
|
| Rate for Payer: United Healthcare All Payer |
$25.53
|
|
|
FRAGILE X GENE DETECTION
|
Facility
|
OP
|
$490.00
|
|
|
Service Code
|
HCPCS 81243
|
| Hospital Charge Code |
30000189
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$57.04 |
| Max. Negotiated Rate |
$470.40 |
| Rate for Payer: Aetna Commercial |
$377.30
|
| Rate for Payer: Anthem Medicaid |
$57.04
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$57.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.47
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$79.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$57.04
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$406.70
|
| Rate for Payer: First Health Commercial |
$465.50
|
| Rate for Payer: Humana Commercial |
$416.50
|
| Rate for Payer: Humana KY Medicaid |
$57.04
|
| Rate for Payer: Humana Medicare Advantage |
$57.04
|
| Rate for Payer: Kentucky WC Medicaid |
$57.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$401.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$361.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$68.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$58.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$431.20
|
| Rate for Payer: Ohio Health Group HMO |
$367.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$338.10
|
| Rate for Payer: PHCS Commercial |
$470.40
|
| Rate for Payer: United Healthcare All Payer |
$431.20
|
|
|
FRAGILE X GENE DETECTION
|
Facility
|
IP
|
$490.00
|
|
|
Service Code
|
HCPCS 81243
|
| Hospital Charge Code |
30000189
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$147.00 |
| Max. Negotiated Rate |
$470.40 |
| Rate for Payer: Aetna Commercial |
$377.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$393.47
|
| Rate for Payer: Cash Price |
$245.00
|
| Rate for Payer: Cigna Commercial |
$406.70
|
| Rate for Payer: First Health Commercial |
$465.50
|
| Rate for Payer: Humana Commercial |
$416.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$401.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$361.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$147.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$431.20
|
| Rate for Payer: Ohio Health Group HMO |
$367.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$392.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$426.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$338.10
|
| Rate for Payer: PHCS Commercial |
$470.40
|
| Rate for Payer: United Healthcare All Payer |
$431.20
|
|
|
FRAGMIN 2500UN (10000UN/1ML)
|
Facility
|
OP
|
$537.79
|
|
|
Service Code
|
HCPCS J1645
|
| Hospital Charge Code |
25003812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.34 |
| Max. Negotiated Rate |
$516.28 |
| Rate for Payer: Aetna Commercial |
$414.10
|
| Rate for Payer: Anthem Medicaid |
$184.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$419.48
|
| Rate for Payer: Cash Price |
$268.90
|
| Rate for Payer: Cigna Commercial |
$446.37
|
| Rate for Payer: First Health Commercial |
$510.90
|
| Rate for Payer: Humana Commercial |
$457.12
|
| Rate for Payer: Humana KY Medicaid |
$184.95
|
| Rate for Payer: Kentucky WC Medicaid |
$186.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$440.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$396.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$188.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$473.26
|
| Rate for Payer: Ohio Health Group HMO |
$403.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$430.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$467.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.08
|
| Rate for Payer: PHCS Commercial |
$516.28
|
| Rate for Payer: United Healthcare All Payer |
$473.26
|
|
|
FRAGMIN 2500UN (10000UN/1ML)
|
Facility
|
IP
|
$537.79
|
|
|
Service Code
|
HCPCS J1645
|
| Hospital Charge Code |
25003812
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.34 |
| Max. Negotiated Rate |
$516.28 |
| Rate for Payer: Aetna Commercial |
$414.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$419.48
|
| Rate for Payer: Cash Price |
$268.90
|
| Rate for Payer: Cigna Commercial |
$446.37
|
| Rate for Payer: First Health Commercial |
$510.90
|
| Rate for Payer: Humana Commercial |
$457.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$440.99
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$396.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$161.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$473.26
|
| Rate for Payer: Ohio Health Group HMO |
$403.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$430.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$467.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$371.08
|
| Rate for Payer: PHCS Commercial |
$516.28
|
| Rate for Payer: United Healthcare All Payer |
$473.26
|
|
|
FRAME ASSEMBLED FOOT 180MM
|
Facility
|
IP
|
$26,888.75
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,066.62 |
| Max. Negotiated Rate |
$25,813.20 |
| Rate for Payer: Aetna Commercial |
$20,704.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,973.22
|
| Rate for Payer: Cash Price |
$13,444.38
|
| Rate for Payer: Cigna Commercial |
$22,317.66
|
| Rate for Payer: First Health Commercial |
$25,544.31
|
| Rate for Payer: Humana Commercial |
$22,855.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,048.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,843.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,066.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,662.10
|
| Rate for Payer: Ohio Health Group HMO |
$20,166.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,511.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,393.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,553.24
|
| Rate for Payer: PHCS Commercial |
$25,813.20
|
| Rate for Payer: United Healthcare All Payer |
$23,662.10
|
|
|
FRAME ASSEMBLED FOOT 180MM
|
Facility
|
OP
|
$26,888.75
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8,066.62 |
| Max. Negotiated Rate |
$25,813.20 |
| Rate for Payer: Aetna Commercial |
$20,704.34
|
| Rate for Payer: Anthem Medicaid |
$9,247.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20,973.22
|
| Rate for Payer: Cash Price |
$13,444.38
|
| Rate for Payer: Cigna Commercial |
$22,317.66
|
| Rate for Payer: First Health Commercial |
$25,544.31
|
| Rate for Payer: Humana Commercial |
$22,855.44
|
| Rate for Payer: Humana KY Medicaid |
$9,247.04
|
| Rate for Payer: Kentucky WC Medicaid |
$9,341.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$22,048.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$19,843.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8,066.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$9,432.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$23,662.10
|
| Rate for Payer: Ohio Health Group HMO |
$20,166.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$21,511.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$23,393.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18,553.24
|
| Rate for Payer: PHCS Commercial |
$25,813.20
|
| Rate for Payer: United Healthcare All Payer |
$23,662.10
|
|
|
FREEDOM ALL POLY CUP 50MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 50MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 52MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 52MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 54MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 54MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 56MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 56MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 58MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 58MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 60MM
|
Facility
|
OP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem Medicaid |
$5,780.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Humana KY Medicaid |
$5,780.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,839.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,896.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
|
FREEDOM ALL POLY CUP 60MM
|
Facility
|
IP
|
$16,809.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,042.94 |
| Max. Negotiated Rate |
$16,137.41 |
| Rate for Payer: Aetna Commercial |
$12,943.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,111.64
|
| Rate for Payer: Cash Price |
$8,404.90
|
| Rate for Payer: Cigna Commercial |
$13,952.13
|
| Rate for Payer: First Health Commercial |
$15,969.31
|
| Rate for Payer: Humana Commercial |
$14,288.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,784.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,405.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,042.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,792.62
|
| Rate for Payer: Ohio Health Group HMO |
$12,607.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$13,447.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14,624.53
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$11,598.76
|
| Rate for Payer: PHCS Commercial |
$16,137.41
|
| Rate for Payer: United Healthcare All Payer |
$14,792.62
|
|
