|
G3 L GAMMA KIT 11*400*130 L TI
|
Facility
|
OP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem Medicaid |
$2,618.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Humana KY Medicaid |
$2,618.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2,644.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,670.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*400*130 L TI
|
Facility
|
IP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*400*130 R TI
|
Facility
|
OP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem Medicaid |
$2,618.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Humana KY Medicaid |
$2,618.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2,644.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,670.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*400*130 R TI
|
Facility
|
IP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*420*130 L TI
|
Facility
|
OP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem Medicaid |
$2,618.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Humana KY Medicaid |
$2,618.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2,644.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,670.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*420*130 L TI
|
Facility
|
IP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*420*130 R TI
|
Facility
|
OP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem Medicaid |
$2,618.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Humana KY Medicaid |
$2,618.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2,644.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,670.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*420*130 R TI
|
Facility
|
IP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*440*130 L TI
|
Facility
|
IP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*440*130 L TI
|
Facility
|
OP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem Medicaid |
$2,618.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Humana KY Medicaid |
$2,618.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2,644.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,670.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*440*130 R TI
|
Facility
|
OP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem Medicaid |
$2,618.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Humana KY Medicaid |
$2,618.32
|
| Rate for Payer: Kentucky WC Medicaid |
$2,644.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,670.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 L GAMMA KIT 11*440*130 R TI
|
Facility
|
IP
|
$7,613.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,284.08 |
| Max. Negotiated Rate |
$7,309.06 |
| Rate for Payer: Aetna Commercial |
$5,862.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,938.61
|
| Rate for Payer: Cash Price |
$3,806.80
|
| Rate for Payer: Cigna Commercial |
$6,319.29
|
| Rate for Payer: First Health Commercial |
$7,232.92
|
| Rate for Payer: Humana Commercial |
$6,471.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,243.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,618.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,284.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,699.97
|
| Rate for Payer: Ohio Health Group HMO |
$5,710.20
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,090.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,623.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,253.38
|
| Rate for Payer: PHCS Commercial |
$7,309.06
|
| Rate for Payer: United Healthcare All Payer |
$6,699.97
|
|
|
G3 TROCHAN NAIL KIT 11*180*125
|
Facility
|
OP
|
$6,839.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,051.94 |
| Max. Negotiated Rate |
$6,566.21 |
| Rate for Payer: Aetna Commercial |
$5,266.65
|
| Rate for Payer: Anthem Medicaid |
$2,352.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,335.04
|
| Rate for Payer: Cash Price |
$3,419.90
|
| Rate for Payer: Cigna Commercial |
$5,677.03
|
| Rate for Payer: First Health Commercial |
$6,497.81
|
| Rate for Payer: Humana Commercial |
$5,813.83
|
| Rate for Payer: Humana KY Medicaid |
$2,352.21
|
| Rate for Payer: Kentucky WC Medicaid |
$2,376.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,608.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,047.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,051.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,399.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,019.02
|
| Rate for Payer: Ohio Health Group HMO |
$5,129.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,471.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,950.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,719.46
|
| Rate for Payer: PHCS Commercial |
$6,566.21
|
| Rate for Payer: United Healthcare All Payer |
$6,019.02
|
|
|
G3 TROCHAN NAIL KIT 11*180*125
|
Facility
|
IP
|
$6,839.80
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000285
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,051.94 |
| Max. Negotiated Rate |
$6,566.21 |
| Rate for Payer: Aetna Commercial |
$5,266.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,335.04
|
| Rate for Payer: Cash Price |
$3,419.90
|
| Rate for Payer: Cigna Commercial |
$5,677.03
|
| Rate for Payer: First Health Commercial |
$6,497.81
|
| Rate for Payer: Humana Commercial |
$5,813.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,608.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,047.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,051.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,019.02
|
| Rate for Payer: Ohio Health Group HMO |
$5,129.85
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,471.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,950.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,719.46
|
| Rate for Payer: PHCS Commercial |
$6,566.21
|
| Rate for Payer: United Healthcare All Payer |
$6,019.02
|
|
|
G7 VIT E NEUTRAL LNR 36MM E
|
Facility
|
IP
|
$10,986.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,296.04 |
| Max. Negotiated Rate |
$10,547.33 |
| Rate for Payer: Aetna Commercial |
$8,459.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,569.70
|
| Rate for Payer: Cash Price |
$5,493.40
|
| Rate for Payer: Cigna Commercial |
$9,119.04
|
| Rate for Payer: First Health Commercial |
$10,437.46
|
| Rate for Payer: Humana Commercial |
$9,338.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,009.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,108.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,296.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,668.38
|
| Rate for Payer: Ohio Health Group HMO |
$8,240.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,789.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,558.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,580.89
|
| Rate for Payer: PHCS Commercial |
$10,547.33
|
| Rate for Payer: United Healthcare All Payer |
$9,668.38
|
|
|
G7 VIT E NEUTRAL LNR 36MM E
|
Facility
|
OP
|
$10,986.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,296.04 |
| Max. Negotiated Rate |
$10,547.33 |
| Rate for Payer: Aetna Commercial |
$8,459.84
|
| Rate for Payer: Anthem Medicaid |
$3,778.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,569.70
|
| Rate for Payer: Cash Price |
$5,493.40
|
| Rate for Payer: Cigna Commercial |
$9,119.04
|
| Rate for Payer: First Health Commercial |
$10,437.46
|
| Rate for Payer: Humana Commercial |
$9,338.78
|
| Rate for Payer: Humana KY Medicaid |
$3,778.36
|
| Rate for Payer: Kentucky WC Medicaid |
$3,816.81
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,009.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,108.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,296.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,854.17
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,668.38
|
| Rate for Payer: Ohio Health Group HMO |
$8,240.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,789.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,558.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,580.89
|
| Rate for Payer: PHCS Commercial |
$10,547.33
|
| Rate for Payer: United Healthcare All Payer |
$9,668.38
|
|
|
GABITRIL 12MG TAB
|
Facility
|
OP
|
$25.73
|
|
|
Service Code
|
NDC 93807256
|
| Hospital Charge Code |
25000708
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$19.81
|
| Rate for Payer: Anthem Medicaid |
$8.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.07
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna Commercial |
$21.36
|
| Rate for Payer: First Health Commercial |
$24.44
|
| Rate for Payer: Humana Commercial |
$21.87
|
| Rate for Payer: Humana KY Medicaid |
$8.85
|
| Rate for Payer: Kentucky WC Medicaid |
$8.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.64
|
| Rate for Payer: Ohio Health Group HMO |
$19.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.75
|
| Rate for Payer: PHCS Commercial |
$24.70
|
| Rate for Payer: United Healthcare All Payer |
$22.64
|
|
|
GABITRIL 12MG TAB
|
Facility
|
IP
|
$25.73
|
|
|
Service Code
|
NDC 93807256
|
| Hospital Charge Code |
25000708
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$24.70 |
| Rate for Payer: Aetna Commercial |
$19.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$20.07
|
| Rate for Payer: Cash Price |
$12.87
|
| Rate for Payer: Cigna Commercial |
$21.36
|
| Rate for Payer: First Health Commercial |
$24.44
|
| Rate for Payer: Humana Commercial |
$21.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$21.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$22.64
|
| Rate for Payer: Ohio Health Group HMO |
$19.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$20.58
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$22.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.75
|
| Rate for Payer: PHCS Commercial |
$24.70
|
| Rate for Payer: United Healthcare All Payer |
$22.64
|
|
|
GABITRIL 16MG TAB
|
Facility
|
OP
|
$28.43
|
|
|
Service Code
|
NDC 93807656
|
| Hospital Charge Code |
25000709
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Aetna Commercial |
$21.89
|
| Rate for Payer: Anthem Medicaid |
$9.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.18
|
| Rate for Payer: Cash Price |
$14.21
|
| Rate for Payer: Cigna Commercial |
$23.60
|
| Rate for Payer: First Health Commercial |
$27.01
|
| Rate for Payer: Humana Commercial |
$24.17
|
| Rate for Payer: Humana KY Medicaid |
$9.78
|
| Rate for Payer: Kentucky WC Medicaid |
$9.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$9.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.02
|
| Rate for Payer: Ohio Health Group HMO |
$21.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.62
|
| Rate for Payer: PHCS Commercial |
$27.29
|
| Rate for Payer: United Healthcare All Payer |
$25.02
|
|
|
GABITRIL 16MG TAB
|
Facility
|
IP
|
$28.43
|
|
|
Service Code
|
NDC 93807656
|
| Hospital Charge Code |
25000709
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$27.29 |
| Rate for Payer: Aetna Commercial |
$21.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$22.18
|
| Rate for Payer: Cash Price |
$14.21
|
| Rate for Payer: Cigna Commercial |
$23.60
|
| Rate for Payer: First Health Commercial |
$27.01
|
| Rate for Payer: Humana Commercial |
$24.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$23.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$20.98
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$8.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$25.02
|
| Rate for Payer: Ohio Health Group HMO |
$21.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.74
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$24.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$19.62
|
| Rate for Payer: PHCS Commercial |
$27.29
|
| Rate for Payer: United Healthcare All Payer |
$25.02
|
|
|
GABITRIL (TIAGABINE) 2MG TAB
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
NDC 62756020083
|
| Hospital Charge Code |
25000706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem Medicaid |
$8.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Humana KY Medicaid |
$8.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.11
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GABITRIL (TIAGABINE) 2MG TAB
|
Facility
|
IP
|
$23.35
|
|
|
Service Code
|
NDC 62756020083
|
| Hospital Charge Code |
25000706
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.11
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GABITRIL (TIAGABINE) 4MG
|
Facility
|
IP
|
$23.35
|
|
|
Service Code
|
NDC 62756022483
|
| Hospital Charge Code |
25000707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.11
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GABITRIL (TIAGABINE) 4MG
|
Facility
|
OP
|
$23.35
|
|
|
Service Code
|
NDC 62756022483
|
| Hospital Charge Code |
25000707
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.00 |
| Max. Negotiated Rate |
$22.42 |
| Rate for Payer: Aetna Commercial |
$17.98
|
| Rate for Payer: Anthem Medicaid |
$8.03
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18.21
|
| Rate for Payer: Cash Price |
$11.68
|
| Rate for Payer: Cigna Commercial |
$19.38
|
| Rate for Payer: First Health Commercial |
$22.18
|
| Rate for Payer: Humana Commercial |
$19.85
|
| Rate for Payer: Humana KY Medicaid |
$8.03
|
| Rate for Payer: Kentucky WC Medicaid |
$8.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.55
|
| Rate for Payer: Ohio Health Group HMO |
$17.51
|
| Rate for Payer: Ohio Health Group PPO Differential |
$18.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16.11
|
| Rate for Payer: PHCS Commercial |
$22.42
|
| Rate for Payer: United Healthcare All Payer |
$20.55
|
|
|
GAIT TR INC STAIRS - 15 MIN
|
Facility
|
IP
|
$114.00
|
|
|
Service Code
|
HCPCS 97116
|
| Hospital Charge Code |
42000020
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$109.44 |
| Rate for Payer: Aetna Commercial |
$87.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.92
|
| Rate for Payer: Cash Price |
$57.00
|
| Rate for Payer: Cigna Commercial |
$94.62
|
| Rate for Payer: First Health Commercial |
$108.30
|
| Rate for Payer: Humana Commercial |
$96.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$93.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$84.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$100.32
|
| Rate for Payer: Ohio Health Group HMO |
$85.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$91.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$99.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$78.66
|
| Rate for Payer: PHCS Commercial |
$109.44
|
| Rate for Payer: United Healthcare All Payer |
$100.32
|
|
