|
GI: UPPER W/AIR CONTRAST
|
Facility
|
OP
|
$940.00
|
|
|
Service Code
|
HCPCS 74246
|
| Hospital Charge Code |
32000133
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$122.20 |
| Max. Negotiated Rate |
$902.40 |
| Rate for Payer: Aetna Commercial |
$723.80
|
| Rate for Payer: Anthem Medicaid |
$323.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$733.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cash Price |
$470.00
|
| Rate for Payer: Cigna Commercial |
$780.20
|
| Rate for Payer: First Health Commercial |
$893.00
|
| Rate for Payer: Humana Commercial |
$799.00
|
| Rate for Payer: Humana KY Medicaid |
$323.27
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$326.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$770.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$693.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$329.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$827.20
|
| Rate for Payer: Ohio Health Group HMO |
$705.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$188.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$122.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$291.40
|
| Rate for Payer: PHCS Commercial |
$902.40
|
| Rate for Payer: United Healthcare All Payer |
$827.20
|
|
|
GI: UPPER W/AIR CONTRAST(P
|
Professional
|
Both
|
$100.00
|
|
|
Service Code
|
HCPCS 74246
|
| Hospital Charge Code |
320P0133
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$35.00 |
| Max. Negotiated Rate |
$186.10 |
| Rate for Payer: Aetna Commercial |
$186.10
|
| Rate for Payer: Anthem Medicaid |
$104.03
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna Commercial |
$157.57
|
| Rate for Payer: Healthspan PPO |
$174.38
|
| Rate for Payer: Humana Medicaid |
$104.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$44.13
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$106.11
|
| Rate for Payer: Molina Healthcare Passport |
$104.03
|
| Rate for Payer: Multiplan PHCS |
$60.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$70.00
|
| Rate for Payer: UHCCP Medicaid |
$35.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$105.07
|
|
|
GI: UPPER W/AIR CONTRAST(T
|
Facility
|
OP
|
$840.00
|
|
|
Service Code
|
HCPCS 74246
|
| Hospital Charge Code |
320T0133
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna Commercial |
$646.80
|
| Rate for Payer: Anthem Medicaid |
$288.88
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$158.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$655.20
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$222.43
|
| Rate for Payer: CareSource Just4Me Medicare |
$214.49
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: Cigna Commercial |
$697.20
|
| Rate for Payer: First Health Commercial |
$798.00
|
| Rate for Payer: Humana Commercial |
$714.00
|
| Rate for Payer: Humana KY Medicaid |
$288.88
|
| Rate for Payer: Humana Medicare Advantage |
$158.88
|
| Rate for Payer: Kentucky WC Medicaid |
$291.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$688.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$619.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$190.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$294.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$739.20
|
| Rate for Payer: Ohio Health Group HMO |
$630.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$260.40
|
| Rate for Payer: PHCS Commercial |
$806.40
|
| Rate for Payer: United Healthcare All Payer |
$739.20
|
|
|
GI: UPPER W/AIR CONTRAST(T
|
Facility
|
IP
|
$840.00
|
|
|
Service Code
|
HCPCS 74246
|
| Hospital Charge Code |
320T0133
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$109.20 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna Commercial |
$646.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$655.20
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: Cigna Commercial |
$697.20
|
| Rate for Payer: First Health Commercial |
$798.00
|
| Rate for Payer: Humana Commercial |
$714.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$688.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$619.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$252.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$739.20
|
| Rate for Payer: Ohio Health Group HMO |
$630.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$168.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$109.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$260.40
|
| Rate for Payer: PHCS Commercial |
$806.40
|
| Rate for Payer: United Healthcare All Payer |
$739.20
|
|
|
GLASSIA 10MG (1000MG VL)
|
Facility
|
IP
|
$3,488.00
|
|
|
Service Code
|
HCPCS J0257
|
| Hospital Charge Code |
25001850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$453.44 |
| Max. Negotiated Rate |
$3,348.48 |
| Rate for Payer: Aetna Commercial |
$2,685.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,720.64
|
| Rate for Payer: Cash Price |
$1,744.00
|
| Rate for Payer: Cigna Commercial |
$2,895.04
|
| Rate for Payer: First Health Commercial |
$3,313.60
|
| Rate for Payer: Humana Commercial |
$2,964.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,860.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,574.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,046.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,069.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,616.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$697.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$453.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,081.28
|
| Rate for Payer: PHCS Commercial |
$3,348.48
|
| Rate for Payer: United Healthcare All Payer |
$3,069.44
|
|
|
GLASSIA 10MG (1000MG VL)
|
Facility
|
OP
|
$3,488.00
|
|
|
Service Code
|
HCPCS J0257
|
| Hospital Charge Code |
25001850
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.35 |
| Max. Negotiated Rate |
$3,348.48 |
| Rate for Payer: Aetna Commercial |
$2,685.76
|
| Rate for Payer: Anthem Medicaid |
$1,199.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$5.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,720.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$7.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$7.23
|
| Rate for Payer: Cash Price |
$1,744.00
|
| Rate for Payer: Cash Price |
$1,744.00
|
| Rate for Payer: Cigna Commercial |
$2,895.04
|
| Rate for Payer: First Health Commercial |
$3,313.60
|
| Rate for Payer: Humana Commercial |
$2,964.80
|
| Rate for Payer: Humana KY Medicaid |
$1,199.52
|
| Rate for Payer: Humana Medicare Advantage |
$5.35
|
| Rate for Payer: Kentucky WC Medicaid |
$1,211.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,860.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,574.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.42
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,223.59
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,069.44
|
| Rate for Payer: Ohio Health Group HMO |
$2,616.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$697.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$453.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,081.28
|
| Rate for Payer: PHCS Commercial |
$3,348.48
|
| Rate for Payer: United Healthcare All Payer |
$3,069.44
|
|
|
GLEEVEC 100MG TABLET
|
Facility
|
IP
|
$510.34
|
|
|
Service Code
|
NDC 78040134
|
| Hospital Charge Code |
25000722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.34 |
| Max. Negotiated Rate |
$489.93 |
| Rate for Payer: Aetna Commercial |
$392.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$398.07
|
| Rate for Payer: Cash Price |
$255.17
|
| Rate for Payer: Cigna Commercial |
$423.58
|
| Rate for Payer: First Health Commercial |
$484.82
|
| Rate for Payer: Humana Commercial |
$433.79
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$449.10
|
| Rate for Payer: Ohio Health Group HMO |
$382.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.21
|
| Rate for Payer: PHCS Commercial |
$489.93
|
| Rate for Payer: United Healthcare All Payer |
$449.10
|
|
|
GLEEVEC 100MG TABLET
|
Facility
|
OP
|
$510.34
|
|
|
Service Code
|
NDC 78040134
|
| Hospital Charge Code |
25000722
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.34 |
| Max. Negotiated Rate |
$489.93 |
| Rate for Payer: Aetna Commercial |
$392.96
|
| Rate for Payer: Anthem Medicaid |
$175.51
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$398.07
|
| Rate for Payer: Cash Price |
$255.17
|
| Rate for Payer: Cigna Commercial |
$423.58
|
| Rate for Payer: First Health Commercial |
$484.82
|
| Rate for Payer: Humana Commercial |
$433.79
|
| Rate for Payer: Humana KY Medicaid |
$175.51
|
| Rate for Payer: Kentucky WC Medicaid |
$177.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$418.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$376.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$153.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$179.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$449.10
|
| Rate for Payer: Ohio Health Group HMO |
$382.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$102.07
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$66.34
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$158.21
|
| Rate for Payer: PHCS Commercial |
$489.93
|
| Rate for Payer: United Healthcare All Payer |
$449.10
|
|
|
GLEEVEC 400MG TABLET
|
Facility
|
IP
|
$1,838.88
|
|
|
Service Code
|
NDC 78064913
|
| Hospital Charge Code |
25000723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$239.05 |
| Max. Negotiated Rate |
$1,765.32 |
| Rate for Payer: Aetna Commercial |
$1,415.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,434.33
|
| Rate for Payer: Cash Price |
$919.44
|
| Rate for Payer: Cigna Commercial |
$1,526.27
|
| Rate for Payer: First Health Commercial |
$1,746.94
|
| Rate for Payer: Humana Commercial |
$1,563.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,507.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,357.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$551.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,618.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,379.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$367.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$570.05
|
| Rate for Payer: PHCS Commercial |
$1,765.32
|
| Rate for Payer: United Healthcare All Payer |
$1,618.21
|
|
|
GLEEVEC 400MG TABLET
|
Facility
|
OP
|
$1,838.88
|
|
|
Service Code
|
NDC 78064913
|
| Hospital Charge Code |
25000723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$239.05 |
| Max. Negotiated Rate |
$1,765.32 |
| Rate for Payer: Humana Commercial |
$1,563.05
|
| Rate for Payer: Humana KY Medicaid |
$632.39
|
| Rate for Payer: Kentucky WC Medicaid |
$638.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,507.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,357.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$551.66
|
| Rate for Payer: Molina Healthcare Medicaid |
$645.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,618.21
|
| Rate for Payer: Ohio Health Group HMO |
$1,379.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$367.78
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$239.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$570.05
|
| Rate for Payer: PHCS Commercial |
$1,765.32
|
| Rate for Payer: United Healthcare All Payer |
$1,618.21
|
| Rate for Payer: Aetna Commercial |
$1,415.94
|
| Rate for Payer: Anthem Medicaid |
$632.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,434.33
|
| Rate for Payer: Cash Price |
$919.44
|
| Rate for Payer: Cigna Commercial |
$1,526.27
|
| Rate for Payer: First Health Commercial |
$1,746.94
|
|
|
GLENOD 53/50 HED ART 19*20M CE
|
Facility
|
IP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 53/50 HED ART 19*20M CE
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 53/50 HED ART 20*25M CE
|
Facility
|
IP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 53/50 HED ART 20*25M CE
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 58/55 HED ART 19*20M CE
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 58/55 HED ART 19*20M CE
|
Facility
|
IP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 58/55 HED ART 20*25M CE
|
Facility
|
IP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD 58/55 HED ART 20*25M CE
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOD W/46MM SURFCE PEGS 40MM
|
Facility
|
IP
|
$9,159.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.77 |
| Max. Negotiated Rate |
$8,793.37 |
| Rate for Payer: Aetna Commercial |
$7,053.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,144.61
|
| Rate for Payer: Cash Price |
$4,579.88
|
| Rate for Payer: Cigna Commercial |
$7,602.60
|
| Rate for Payer: First Health Commercial |
$8,701.77
|
| Rate for Payer: Humana Commercial |
$7,785.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,511.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,759.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,747.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,060.59
|
| Rate for Payer: Ohio Health Group HMO |
$6,869.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,831.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,190.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,839.53
|
| Rate for Payer: PHCS Commercial |
$8,793.37
|
| Rate for Payer: United Healthcare All Payer |
$8,060.59
|
|
|
GLENOD W/46MM SURFCE PEGS 40MM
|
Facility
|
OP
|
$9,159.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,190.77 |
| Max. Negotiated Rate |
$8,793.37 |
| Rate for Payer: Aetna Commercial |
$7,053.02
|
| Rate for Payer: Anthem Medicaid |
$3,150.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,144.61
|
| Rate for Payer: Cash Price |
$4,579.88
|
| Rate for Payer: Cigna Commercial |
$7,602.60
|
| Rate for Payer: First Health Commercial |
$8,701.77
|
| Rate for Payer: Humana Commercial |
$7,785.80
|
| Rate for Payer: Humana KY Medicaid |
$3,150.04
|
| Rate for Payer: Kentucky WC Medicaid |
$3,182.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,511.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,759.90
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,747.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,213.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,060.59
|
| Rate for Payer: Ohio Health Group HMO |
$6,869.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,831.95
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,190.77
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,839.53
|
| Rate for Payer: PHCS Commercial |
$8,793.37
|
| Rate for Payer: United Healthcare All Payer |
$8,060.59
|
|
|
GLENOID 53/50 HEAD ART 19*20M
|
Facility
|
IP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOID 53/50 HEAD ART 19*20M
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOID 53/50 HEAD ART 20*25M
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOID 53/50 HEAD ART 20*25M
|
Facility
|
IP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
|
GLENOID 58/55 HEAD ART 19*20MM
|
Facility
|
OP
|
$8,738.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,136.01 |
| Max. Negotiated Rate |
$8,389.01 |
| Rate for Payer: Aetna Commercial |
$6,728.68
|
| Rate for Payer: Anthem Medicaid |
$3,005.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,816.07
|
| Rate for Payer: Cash Price |
$4,369.27
|
| Rate for Payer: Cigna Commercial |
$7,253.00
|
| Rate for Payer: First Health Commercial |
$8,301.62
|
| Rate for Payer: Humana Commercial |
$7,427.77
|
| Rate for Payer: Humana KY Medicaid |
$3,005.19
|
| Rate for Payer: Kentucky WC Medicaid |
$3,035.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,165.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,449.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,621.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,065.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,689.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,553.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,747.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,136.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,708.95
|
| Rate for Payer: PHCS Commercial |
$8,389.01
|
| Rate for Payer: United Healthcare All Payer |
$7,689.92
|
|
