|
GLEEVEC 400MG TABLET
|
Facility
|
OP
|
$1,838.88
|
|
|
Service Code
|
NDC 78064913
|
| Hospital Charge Code |
25000723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$551.66 |
| Max. Negotiated Rate |
$1,765.32 |
| 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
|
| 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 |
$1,471.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,599.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,268.83
|
| Rate for Payer: PHCS Commercial |
$1,765.32
|
| Rate for Payer: United Healthcare All Payer |
$1,618.21
|
|
|
GLEEVEC 400MG TABLET
|
Facility
|
IP
|
$1,838.88
|
|
|
Service Code
|
NDC 78064913
|
| Hospital Charge Code |
25000723
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$551.66 |
| 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 |
$1,471.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,599.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,268.83
|
| Rate for Payer: PHCS Commercial |
$1,765.32
|
| Rate for Payer: United Healthcare All Payer |
$1,618.21
|
|
|
GLENOD 53/50 HED ART 19*20M CE
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 53/50 HED ART 19*20M CE
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 53/50 HED ART 20*25M CE
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 53/50 HED ART 20*25M CE
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 58/55 HED ART 19*20M CE
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 58/55 HED ART 19*20M CE
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 58/55 HED ART 20*25M CE
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD 58/55 HED ART 20*25M CE
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOD W/46MM SURFCE PEGS 40MM
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
GLENOD W/46MM SURFCE PEGS 40MM
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
GLENOID 53/50 HEAD ART 19*20M
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 53/50 HEAD ART 19*20M
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 53/50 HEAD ART 20*25M
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 53/50 HEAD ART 20*25M
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 58/55 HEAD ART 19*20MM
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 58/55 HEAD ART 19*20MM
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 58/55 HEAD ART 20*25M
|
Facility
|
IP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID 58/55 HEAD ART 20*25M
|
Facility
|
OP
|
$8,938.55
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,681.57 |
| Max. Negotiated Rate |
$8,581.01 |
| Rate for Payer: Aetna Commercial |
$6,882.68
|
| Rate for Payer: Anthem Medicaid |
$3,073.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,972.07
|
| Rate for Payer: Cash Price |
$4,469.27
|
| Rate for Payer: Cigna Commercial |
$7,419.00
|
| Rate for Payer: First Health Commercial |
$8,491.62
|
| Rate for Payer: Humana Commercial |
$7,597.77
|
| Rate for Payer: Humana KY Medicaid |
$3,073.97
|
| Rate for Payer: Kentucky WC Medicaid |
$3,105.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,329.61
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,596.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,681.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,135.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,865.92
|
| Rate for Payer: Ohio Health Group HMO |
$6,703.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,150.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,776.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,167.60
|
| Rate for Payer: PHCS Commercial |
$8,581.01
|
| Rate for Payer: United Healthcare All Payer |
$7,865.92
|
|
|
GLENOID AUG VAULTLOCK LG 15L
|
Facility
|
OP
|
$15,777.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,733.25 |
| Max. Negotiated Rate |
$15,146.40 |
| Rate for Payer: Aetna Commercial |
$12,148.67
|
| Rate for Payer: Anthem Medicaid |
$5,425.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,306.45
|
| Rate for Payer: Cash Price |
$7,888.75
|
| Rate for Payer: Cigna Commercial |
$13,095.33
|
| Rate for Payer: First Health Commercial |
$14,988.62
|
| Rate for Payer: Humana Commercial |
$13,410.88
|
| Rate for Payer: Humana KY Medicaid |
$5,425.88
|
| Rate for Payer: Kentucky WC Medicaid |
$5,481.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,937.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,643.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,733.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,534.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,884.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,833.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,726.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,886.48
|
| Rate for Payer: PHCS Commercial |
$15,146.40
|
| Rate for Payer: United Healthcare All Payer |
$13,884.20
|
|
|
GLENOID AUG VAULTLOCK LG 15L
|
Facility
|
IP
|
$15,777.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,733.25 |
| Max. Negotiated Rate |
$15,146.40 |
| Rate for Payer: Aetna Commercial |
$12,148.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,306.45
|
| Rate for Payer: Cash Price |
$7,888.75
|
| Rate for Payer: Cigna Commercial |
$13,095.33
|
| Rate for Payer: First Health Commercial |
$14,988.62
|
| Rate for Payer: Humana Commercial |
$13,410.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,937.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,643.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,733.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,884.20
|
| Rate for Payer: Ohio Health Group HMO |
$11,833.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12,622.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$13,726.42
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10,886.48
|
| Rate for Payer: PHCS Commercial |
$15,146.40
|
| Rate for Payer: United Healthcare All Payer |
$13,884.20
|
|
|
GLENOID BEARING INSERT STD
|
Facility
|
OP
|
$4,460.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,338.00 |
| Max. Negotiated Rate |
$4,281.60 |
| Rate for Payer: Aetna Commercial |
$3,434.20
|
| Rate for Payer: Anthem Medicaid |
$1,533.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,478.80
|
| Rate for Payer: Cash Price |
$2,230.00
|
| Rate for Payer: Cigna Commercial |
$3,701.80
|
| Rate for Payer: First Health Commercial |
$4,237.00
|
| Rate for Payer: Humana Commercial |
$3,791.00
|
| Rate for Payer: Humana KY Medicaid |
$1,533.79
|
| Rate for Payer: Kentucky WC Medicaid |
$1,549.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,657.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,291.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,338.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,564.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,924.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,568.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,880.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,077.40
|
| Rate for Payer: PHCS Commercial |
$4,281.60
|
| Rate for Payer: United Healthcare All Payer |
$3,924.80
|
|
|
GLENOID BEARING INSERT STD
|
Facility
|
IP
|
$4,460.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,338.00 |
| Max. Negotiated Rate |
$4,281.60 |
| Rate for Payer: Aetna Commercial |
$3,434.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,478.80
|
| Rate for Payer: Cash Price |
$2,230.00
|
| Rate for Payer: Cigna Commercial |
$3,701.80
|
| Rate for Payer: First Health Commercial |
$4,237.00
|
| Rate for Payer: Humana Commercial |
$3,791.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,657.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,291.48
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,338.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,924.80
|
| Rate for Payer: Ohio Health Group HMO |
$3,345.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,568.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,880.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,077.40
|
| Rate for Payer: PHCS Commercial |
$4,281.60
|
| Rate for Payer: United Healthcare All Payer |
$3,924.80
|
|
|
GLENOID DIA 36
|
Facility
|
OP
|
$8,058.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,417.67 |
| Max. Negotiated Rate |
$7,736.54 |
| Rate for Payer: Aetna Commercial |
$6,205.35
|
| Rate for Payer: Anthem Medicaid |
$2,771.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,285.94
|
| Rate for Payer: Cash Price |
$4,029.45
|
| Rate for Payer: Cigna Commercial |
$6,688.89
|
| Rate for Payer: First Health Commercial |
$7,655.95
|
| Rate for Payer: Humana Commercial |
$6,850.06
|
| Rate for Payer: Humana KY Medicaid |
$2,771.46
|
| Rate for Payer: Kentucky WC Medicaid |
$2,799.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,608.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,947.47
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,417.67
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,827.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,091.83
|
| Rate for Payer: Ohio Health Group HMO |
$6,044.18
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,447.12
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,011.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,560.64
|
| Rate for Payer: PHCS Commercial |
$7,736.54
|
| Rate for Payer: United Healthcare All Payer |
$7,091.83
|
|
