|
GEN II PS HGH FLXART INSTSZ7-8
|
Facility
|
OP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem Medicaid |
$1,750.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Humana KY Medicaid |
$1,750.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1,768.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,785.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
GEN II PS HGH FLXART INSTSZ7-8
|
Facility
|
IP
|
$5,090.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,527.00 |
| Max. Negotiated Rate |
$4,886.40 |
| Rate for Payer: Aetna Commercial |
$3,919.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,970.20
|
| Rate for Payer: Cash Price |
$2,545.00
|
| Rate for Payer: Cigna Commercial |
$4,224.70
|
| Rate for Payer: First Health Commercial |
$4,835.50
|
| Rate for Payer: Humana Commercial |
$4,326.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,173.80
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,756.42
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,527.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,479.20
|
| Rate for Payer: Ohio Health Group HMO |
$3,817.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,072.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,428.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.10
|
| Rate for Payer: PHCS Commercial |
$4,886.40
|
| Rate for Payer: United Healthcare All Payer |
$4,479.20
|
|
|
GEN II TIBIAL NP SZ 4 LT
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 4 LT
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 4 RT
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 4 RT
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 5 LT
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 5 LT
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 5 RT
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GEN II TIBIAL NP SZ 5 RT
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
GENISS II L NON PORUS TIB BASE
|
Facility
|
IP
|
$9,235.66
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,770.70 |
| Max. Negotiated Rate |
$8,866.23 |
| Rate for Payer: Aetna Commercial |
$7,111.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,203.81
|
| Rate for Payer: Cash Price |
$4,617.83
|
| Rate for Payer: Cigna Commercial |
$7,665.60
|
| Rate for Payer: First Health Commercial |
$8,773.88
|
| Rate for Payer: Humana Commercial |
$7,850.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,573.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,815.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,770.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,127.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,926.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,388.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,035.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,372.61
|
| Rate for Payer: PHCS Commercial |
$8,866.23
|
| Rate for Payer: United Healthcare All Payer |
$8,127.38
|
|
|
GENISS II L NON PORUS TIB BASE
|
Facility
|
OP
|
$9,235.66
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,770.70 |
| Max. Negotiated Rate |
$8,866.23 |
| Rate for Payer: Aetna Commercial |
$7,111.46
|
| Rate for Payer: Anthem Medicaid |
$3,176.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,203.81
|
| Rate for Payer: Cash Price |
$4,617.83
|
| Rate for Payer: Cigna Commercial |
$7,665.60
|
| Rate for Payer: First Health Commercial |
$8,773.88
|
| Rate for Payer: Humana Commercial |
$7,850.31
|
| Rate for Payer: Humana KY Medicaid |
$3,176.14
|
| Rate for Payer: Kentucky WC Medicaid |
$3,208.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,573.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,815.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,770.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,239.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,127.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,926.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,388.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,035.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,372.61
|
| Rate for Payer: PHCS Commercial |
$8,866.23
|
| Rate for Payer: United Healthcare All Payer |
$8,127.38
|
|
|
GENISS II RT NONPORUS TIB BASE
|
Facility
|
OP
|
$7,607.21
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,282.16 |
| Max. Negotiated Rate |
$7,302.92 |
| Rate for Payer: Aetna Commercial |
$5,857.55
|
| Rate for Payer: Anthem Medicaid |
$2,616.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,933.62
|
| Rate for Payer: Cash Price |
$3,803.61
|
| Rate for Payer: Cigna Commercial |
$6,313.98
|
| Rate for Payer: First Health Commercial |
$7,226.85
|
| Rate for Payer: Humana Commercial |
$6,466.13
|
| Rate for Payer: Humana KY Medicaid |
$2,616.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,642.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,237.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,614.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,282.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,668.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,694.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,705.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,085.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,618.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,248.97
|
| Rate for Payer: PHCS Commercial |
$7,302.92
|
| Rate for Payer: United Healthcare All Payer |
$6,694.34
|
|
|
GENISS II RT NONPORUS TIB BASE
|
Facility
|
IP
|
$7,607.21
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,282.16 |
| Max. Negotiated Rate |
$7,302.92 |
| Rate for Payer: Aetna Commercial |
$5,857.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,933.62
|
| Rate for Payer: Cash Price |
$3,803.61
|
| Rate for Payer: Cigna Commercial |
$6,313.98
|
| Rate for Payer: First Health Commercial |
$7,226.85
|
| Rate for Payer: Humana Commercial |
$6,466.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,237.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,614.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,282.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,694.34
|
| Rate for Payer: Ohio Health Group HMO |
$5,705.41
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,085.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,618.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,248.97
|
| Rate for Payer: PHCS Commercial |
$7,302.92
|
| Rate for Payer: United Healthcare All Payer |
$6,694.34
|
|
|
GENOTROPIN 0.2MG/0.25ML SYR
|
Facility
|
IP
|
$186.36
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.91 |
| Max. Negotiated Rate |
$178.91 |
| Rate for Payer: Aetna Commercial |
$143.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.36
|
| Rate for Payer: Cash Price |
$93.18
|
| Rate for Payer: Cigna Commercial |
$154.68
|
| Rate for Payer: First Health Commercial |
$177.04
|
| Rate for Payer: Humana Commercial |
$158.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$55.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.00
|
| Rate for Payer: Ohio Health Group HMO |
$139.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.59
|
| Rate for Payer: PHCS Commercial |
$178.91
|
| Rate for Payer: United Healthcare All Payer |
$164.00
|
|
|
GENOTROPIN 0.2MG/0.25ML SYR
|
Facility
|
OP
|
$186.36
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002366
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$178.91 |
| Rate for Payer: Aetna Commercial |
$143.50
|
| Rate for Payer: Anthem Medicaid |
$64.09
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$145.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$68.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.04
|
| Rate for Payer: Cash Price |
$93.18
|
| Rate for Payer: Cash Price |
$93.18
|
| Rate for Payer: Cigna Commercial |
$154.68
|
| Rate for Payer: First Health Commercial |
$177.04
|
| Rate for Payer: Humana Commercial |
$158.41
|
| Rate for Payer: Humana KY Medicaid |
$64.09
|
| Rate for Payer: Humana Medicare Advantage |
$48.92
|
| Rate for Payer: Kentucky WC Medicaid |
$64.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$152.82
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$137.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$65.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$164.00
|
| Rate for Payer: Ohio Health Group HMO |
$139.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$149.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$162.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$128.59
|
| Rate for Payer: PHCS Commercial |
$178.91
|
| Rate for Payer: United Healthcare All Payer |
$164.00
|
|
|
GENOTROPIN 0.4MG/0.25ML SYR
|
Facility
|
OP
|
$331.18
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002367
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$48.92 |
| Max. Negotiated Rate |
$317.93 |
| Rate for Payer: Aetna Commercial |
$255.01
|
| Rate for Payer: Anthem Medicaid |
$113.89
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$48.92
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$258.32
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$68.49
|
| Rate for Payer: CareSource Just4Me Medicare |
$66.04
|
| Rate for Payer: Cash Price |
$165.59
|
| Rate for Payer: Cash Price |
$165.59
|
| Rate for Payer: Cigna Commercial |
$274.88
|
| Rate for Payer: First Health Commercial |
$314.62
|
| Rate for Payer: Humana Commercial |
$281.50
|
| Rate for Payer: Humana KY Medicaid |
$113.89
|
| Rate for Payer: Humana Medicare Advantage |
$48.92
|
| Rate for Payer: Kentucky WC Medicaid |
$115.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$271.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$58.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$116.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$291.44
|
| Rate for Payer: Ohio Health Group HMO |
$248.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$264.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$288.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.51
|
| Rate for Payer: PHCS Commercial |
$317.93
|
| Rate for Payer: United Healthcare All Payer |
$291.44
|
|
|
GENOTROPIN 0.4MG/0.25ML SYR
|
Facility
|
IP
|
$331.18
|
|
|
Service Code
|
HCPCS J2941
|
| Hospital Charge Code |
25002367
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$99.35 |
| Max. Negotiated Rate |
$317.93 |
| Rate for Payer: Aetna Commercial |
$255.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$258.32
|
| Rate for Payer: Cash Price |
$165.59
|
| Rate for Payer: Cigna Commercial |
$274.88
|
| Rate for Payer: First Health Commercial |
$314.62
|
| Rate for Payer: Humana Commercial |
$281.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$271.57
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$99.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$291.44
|
| Rate for Payer: Ohio Health Group HMO |
$248.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$264.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$288.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$228.51
|
| Rate for Payer: PHCS Commercial |
$317.93
|
| Rate for Payer: United Healthcare All Payer |
$291.44
|
|
|
GEN P/S ART INSR *LGE LT 10 MM
|
Facility
|
IP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
|
GEN P/S ART INSR *LGE LT 10 MM
|
Facility
|
OP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem Medicaid |
$3,090.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Humana KY Medicaid |
$3,090.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,121.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,152.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
|
GEN P/S ART INSR *LGE LT 12 MM
|
Facility
|
OP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem Medicaid |
$3,090.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Humana KY Medicaid |
$3,090.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,121.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,152.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
|
GEN P/S ART INSR *LGE LT 12 MM
|
Facility
|
IP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
|
GEN P/S ART INSR *LGE LT 15 MM
|
Facility
|
IP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
|
GEN P/S ART INSR *LGE LT 15 MM
|
Facility
|
OP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem Medicaid |
$3,090.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Humana KY Medicaid |
$3,090.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,121.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,152.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
|
GEN P/S ART INSR *LGE LT 20 MM
|
Facility
|
OP
|
$8,986.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,695.80 |
| Max. Negotiated Rate |
$8,626.56 |
| Rate for Payer: Aetna Commercial |
$6,919.22
|
| Rate for Payer: Anthem Medicaid |
$3,090.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,009.08
|
| Rate for Payer: Cash Price |
$4,493.00
|
| Rate for Payer: Cigna Commercial |
$7,458.38
|
| Rate for Payer: First Health Commercial |
$8,536.70
|
| Rate for Payer: Humana Commercial |
$7,638.10
|
| Rate for Payer: Humana KY Medicaid |
$3,090.29
|
| Rate for Payer: Kentucky WC Medicaid |
$3,121.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,368.52
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,631.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,695.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,152.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,907.68
|
| Rate for Payer: Ohio Health Group HMO |
$6,739.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,188.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,817.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,200.34
|
| Rate for Payer: PHCS Commercial |
$8,626.56
|
| Rate for Payer: United Healthcare All Payer |
$7,907.68
|
|
