|
MAXIPIME 500 MG (1 GRAM VIAL)
|
Facility
|
OP
|
$112.05
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001934
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.57 |
| Max. Negotiated Rate |
$107.57 |
| Rate for Payer: Aetna Commercial |
$86.28
|
| Rate for Payer: Anthem Medicaid |
$38.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$87.40
|
| Rate for Payer: Cash Price |
$56.02
|
| Rate for Payer: Cigna Commercial |
$93.00
|
| Rate for Payer: First Health Commercial |
$106.45
|
| Rate for Payer: Humana Commercial |
$95.24
|
| Rate for Payer: Humana KY Medicaid |
$38.53
|
| Rate for Payer: Kentucky WC Medicaid |
$38.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$91.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$82.69
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$98.60
|
| Rate for Payer: Ohio Health Group HMO |
$84.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$34.74
|
| Rate for Payer: PHCS Commercial |
$107.57
|
| Rate for Payer: United Healthcare All Payer |
$98.60
|
|
|
MAXIPIME 500MG [2GM SYRINGE]
|
Facility
|
OP
|
$116.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.18 |
| Max. Negotiated Rate |
$112.13 |
| Rate for Payer: Humana Commercial |
$99.28
|
| Rate for Payer: Humana KY Medicaid |
$40.17
|
| Rate for Payer: Kentucky WC Medicaid |
$40.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$40.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.78
|
| Rate for Payer: Ohio Health Group HMO |
$87.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.21
|
| Rate for Payer: PHCS Commercial |
$112.13
|
| Rate for Payer: United Healthcare All Payer |
$102.78
|
| Rate for Payer: Aetna Commercial |
$89.94
|
| Rate for Payer: Anthem Medicaid |
$40.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.10
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cigna Commercial |
$96.94
|
| Rate for Payer: First Health Commercial |
$110.96
|
|
|
MAXIPIME 500MG [2GM SYRINGE]
|
Facility
|
IP
|
$116.80
|
|
|
Service Code
|
HCPCS J0692
|
| Hospital Charge Code |
25001935
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.18 |
| Max. Negotiated Rate |
$112.13 |
| Rate for Payer: Aetna Commercial |
$89.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$91.10
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cigna Commercial |
$96.94
|
| Rate for Payer: First Health Commercial |
$110.96
|
| Rate for Payer: Humana Commercial |
$99.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$95.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$86.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$35.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$102.78
|
| Rate for Payer: Ohio Health Group HMO |
$87.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$23.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$15.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$36.21
|
| Rate for Payer: PHCS Commercial |
$112.13
|
| Rate for Payer: United Healthcare All Payer |
$102.78
|
|
|
MAXITROL (COMB) OPHTH OI 3.5GM
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
25000950
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Anthem Medicaid |
$1.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.36
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna Commercial |
$2.51
|
| Rate for Payer: First Health Commercial |
$2.88
|
| Rate for Payer: Humana Commercial |
$2.58
|
| Rate for Payer: Humana KY Medicaid |
$1.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.67
|
| Rate for Payer: Ohio Health Group HMO |
$2.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.94
|
| Rate for Payer: PHCS Commercial |
$2.91
|
| Rate for Payer: United Healthcare All Payer |
$2.67
|
|
|
MAXITROL (COMB) OPHTH OI 3.5GM
|
Facility
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 24208079535
|
| Hospital Charge Code |
25000950
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$2.91 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2.36
|
| Rate for Payer: Cash Price |
$1.51
|
| Rate for Payer: Cigna Commercial |
$2.51
|
| Rate for Payer: First Health Commercial |
$2.88
|
| Rate for Payer: Humana Commercial |
$2.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$2.67
|
| Rate for Payer: Ohio Health Group HMO |
$2.27
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.94
|
| Rate for Payer: PHCS Commercial |
$2.91
|
| Rate for Payer: United Healthcare All Payer |
$2.67
|
|
|
MAXITROL (NEO/POLY/DEX)OPH 5ML
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 24208083060
|
| Hospital Charge Code |
25000951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.86
|
| Rate for Payer: Humana Commercial |
$0.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.80
|
| Rate for Payer: Ohio Health Group HMO |
$0.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.28
|
| Rate for Payer: PHCS Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Payer |
$0.80
|
|
|
MAXITROL (NEO/POLY/DEX)OPH 5ML
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 24208083060
|
| Hospital Charge Code |
25000951
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Aetna Commercial |
$0.70
|
| Rate for Payer: Anthem Medicaid |
$0.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.71
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna Commercial |
$0.76
|
| Rate for Payer: First Health Commercial |
$0.86
|
| Rate for Payer: Humana Commercial |
$0.77
|
| Rate for Payer: Humana KY Medicaid |
$0.31
|
| Rate for Payer: Kentucky WC Medicaid |
$0.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.80
|
| Rate for Payer: Ohio Health Group HMO |
$0.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.28
|
| Rate for Payer: PHCS Commercial |
$0.87
|
| Rate for Payer: United Healthcare All Payer |
$0.80
|
|
|
MAXZIDE(TRIAM/HCTZ) 37.5M 1TAB
|
Facility
|
OP
|
$4.47
|
|
|
Service Code
|
NDC 68001032700
|
| Hospital Charge Code |
25000952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem Medicaid |
$1.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Humana KY Medicaid |
$1.54
|
| Rate for Payer: Kentucky WC Medicaid |
$1.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
MAXZIDE(TRIAM/HCTZ) 37.5M 1TAB
|
Facility
|
IP
|
$4.47
|
|
|
Service Code
|
NDC 68001032700
|
| Hospital Charge Code |
25000952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.49
|
| Rate for Payer: Cash Price |
$2.23
|
| Rate for Payer: Cigna Commercial |
$3.71
|
| Rate for Payer: First Health Commercial |
$4.25
|
| Rate for Payer: Humana Commercial |
$3.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.67
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.93
|
| Rate for Payer: Ohio Health Group HMO |
$3.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.39
|
| Rate for Payer: PHCS Commercial |
$4.29
|
| Rate for Payer: United Healthcare All Payer |
$3.93
|
|
|
MB2 GUIDE CATH 5F
|
Facility
|
OP
|
$775.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna Commercial |
$597.14
|
| Rate for Payer: Anthem Medicaid |
$266.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.89
|
| Rate for Payer: Cash Price |
$387.75
|
| Rate for Payer: Cigna Commercial |
$643.66
|
| Rate for Payer: First Health Commercial |
$736.72
|
| Rate for Payer: Humana Commercial |
$659.18
|
| Rate for Payer: Humana KY Medicaid |
$266.69
|
| Rate for Payer: Kentucky WC Medicaid |
$269.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.65
|
| Rate for Payer: Molina Healthcare Medicaid |
$272.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.44
|
| Rate for Payer: Ohio Health Group HMO |
$581.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.40
|
| Rate for Payer: PHCS Commercial |
$744.48
|
| Rate for Payer: United Healthcare All Payer |
$682.44
|
|
|
MB2 GUIDE CATH 5F
|
Facility
|
IP
|
$775.50
|
|
|
Service Code
|
HCPCS C1887
|
| Hospital Charge Code |
27000243
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$100.82 |
| Max. Negotiated Rate |
$744.48 |
| Rate for Payer: Aetna Commercial |
$597.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$604.89
|
| Rate for Payer: Cash Price |
$387.75
|
| Rate for Payer: Cigna Commercial |
$643.66
|
| Rate for Payer: First Health Commercial |
$736.72
|
| Rate for Payer: Humana Commercial |
$659.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$635.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$572.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$232.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$682.44
|
| Rate for Payer: Ohio Health Group HMO |
$581.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$155.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$100.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$240.40
|
| Rate for Payer: PHCS Commercial |
$744.48
|
| Rate for Payer: United Healthcare All Payer |
$682.44
|
|
|
M-BLUE INJ FISTULA TRACT BREAS
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
76102915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
M-BLUE INJ FISTULA TRACT BREAS
|
Professional
|
Both
|
$75.00
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
76102915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Anthem Medicaid |
$250.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$75.00
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Healthspan PPO |
$0.60
|
| Rate for Payer: Humana Medicaid |
$250.00
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$255.00
|
| Rate for Payer: Molina Healthcare Passport |
$250.00
|
| Rate for Payer: Multiplan PHCS |
$45.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$52.50
|
| Rate for Payer: UHCCP Medicaid |
$26.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$252.50
|
|
|
M-BLUE INJ FISTULA TRACT BREAS
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
HCPCS 19499
|
| Hospital Charge Code |
76102915
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$4,614.69 |
| Rate for Payer: Aetna Commercial |
$57.75
|
| Rate for Payer: Anthem Medicaid |
$25.79
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$3,296.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$58.50
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,614.69
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,449.88
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cash Price |
$37.50
|
| Rate for Payer: Cigna Commercial |
$62.25
|
| Rate for Payer: First Health Commercial |
$71.25
|
| Rate for Payer: Humana Commercial |
$63.75
|
| Rate for Payer: Humana KY Medicaid |
$25.79
|
| Rate for Payer: Humana Medicare Advantage |
$3,296.21
|
| Rate for Payer: Kentucky WC Medicaid |
$26.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$61.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$55.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,955.45
|
| Rate for Payer: Molina Healthcare Medicaid |
$26.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$66.00
|
| Rate for Payer: Ohio Health Group HMO |
$56.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$15.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.75
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.25
|
| Rate for Payer: PHCS Commercial |
$72.00
|
| Rate for Payer: United Healthcare All Payer |
$66.00
|
|
|
MBT POROUS TRAY SLEEVE 29MM
|
Facility
|
OP
|
$21,811.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,835.43 |
| Max. Negotiated Rate |
$20,938.57 |
| Rate for Payer: Aetna Commercial |
$16,794.48
|
| Rate for Payer: Anthem Medicaid |
$7,500.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,012.59
|
| Rate for Payer: Cash Price |
$10,905.50
|
| Rate for Payer: Cigna Commercial |
$18,103.14
|
| Rate for Payer: First Health Commercial |
$20,720.46
|
| Rate for Payer: Humana Commercial |
$18,539.36
|
| Rate for Payer: Humana KY Medicaid |
$7,500.81
|
| Rate for Payer: Kentucky WC Medicaid |
$7,577.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,885.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,096.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,543.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,651.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,193.69
|
| Rate for Payer: Ohio Health Group HMO |
$16,358.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,362.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,835.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,761.41
|
| Rate for Payer: PHCS Commercial |
$20,938.57
|
| Rate for Payer: United Healthcare All Payer |
$19,193.69
|
|
|
MBT POROUS TRAY SLEEVE 29MM
|
Facility
|
IP
|
$21,811.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,835.43 |
| Max. Negotiated Rate |
$20,938.57 |
| Rate for Payer: Aetna Commercial |
$16,794.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,012.59
|
| Rate for Payer: Cash Price |
$10,905.50
|
| Rate for Payer: Cigna Commercial |
$18,103.14
|
| Rate for Payer: First Health Commercial |
$20,720.46
|
| Rate for Payer: Humana Commercial |
$18,539.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,885.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,096.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,543.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,193.69
|
| Rate for Payer: Ohio Health Group HMO |
$16,358.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,362.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,835.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,761.41
|
| Rate for Payer: PHCS Commercial |
$20,938.57
|
| Rate for Payer: United Healthcare All Payer |
$19,193.69
|
|
|
MBT POROUS TRAY SLEEVE 37MM
|
Facility
|
IP
|
$24,812.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,225.68 |
| Max. Negotiated Rate |
$23,820.43 |
| Rate for Payer: Aetna Commercial |
$19,105.97
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,354.10
|
| Rate for Payer: Cash Price |
$12,406.48
|
| Rate for Payer: Cigna Commercial |
$20,594.75
|
| Rate for Payer: First Health Commercial |
$23,572.30
|
| Rate for Payer: Humana Commercial |
$21,091.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,346.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,311.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,443.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,835.40
|
| Rate for Payer: Ohio Health Group HMO |
$18,609.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,962.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,225.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,692.01
|
| Rate for Payer: PHCS Commercial |
$23,820.43
|
| Rate for Payer: United Healthcare All Payer |
$21,835.40
|
|
|
MBT POROUS TRAY SLEEVE 37MM
|
Facility
|
OP
|
$24,812.95
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,225.68 |
| Max. Negotiated Rate |
$23,820.43 |
| Rate for Payer: Aetna Commercial |
$19,105.97
|
| Rate for Payer: Anthem Medicaid |
$8,533.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,354.10
|
| Rate for Payer: Cash Price |
$12,406.48
|
| Rate for Payer: Cigna Commercial |
$20,594.75
|
| Rate for Payer: First Health Commercial |
$23,572.30
|
| Rate for Payer: Humana Commercial |
$21,091.01
|
| Rate for Payer: Humana KY Medicaid |
$8,533.17
|
| Rate for Payer: Kentucky WC Medicaid |
$8,620.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,346.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,311.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,443.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,704.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,835.40
|
| Rate for Payer: Ohio Health Group HMO |
$18,609.71
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,962.59
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,225.68
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,692.01
|
| Rate for Payer: PHCS Commercial |
$23,820.43
|
| Rate for Payer: United Healthcare All Payer |
$21,835.40
|
|
|
MBT POROUS TRAY SLEEVE 45MM
|
Facility
|
IP
|
$21,447.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,788.19 |
| Max. Negotiated Rate |
$20,589.74 |
| Rate for Payer: Aetna Commercial |
$16,514.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,729.17
|
| Rate for Payer: Cash Price |
$10,723.83
|
| Rate for Payer: Cigna Commercial |
$17,801.55
|
| Rate for Payer: First Health Commercial |
$20,375.27
|
| Rate for Payer: Humana Commercial |
$18,230.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,587.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,828.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,434.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,873.93
|
| Rate for Payer: Ohio Health Group HMO |
$16,085.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,289.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,788.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,648.77
|
| Rate for Payer: PHCS Commercial |
$20,589.74
|
| Rate for Payer: United Healthcare All Payer |
$18,873.93
|
|
|
MBT POROUS TRAY SLEEVE 45MM
|
Facility
|
OP
|
$21,447.65
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,788.19 |
| Max. Negotiated Rate |
$20,589.74 |
| Rate for Payer: Aetna Commercial |
$16,514.69
|
| Rate for Payer: Anthem Medicaid |
$7,375.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$16,729.17
|
| Rate for Payer: Cash Price |
$10,723.83
|
| Rate for Payer: Cigna Commercial |
$17,801.55
|
| Rate for Payer: First Health Commercial |
$20,375.27
|
| Rate for Payer: Humana Commercial |
$18,230.50
|
| Rate for Payer: Humana KY Medicaid |
$7,375.85
|
| Rate for Payer: Kentucky WC Medicaid |
$7,450.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,587.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$15,828.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,434.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,523.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$18,873.93
|
| Rate for Payer: Ohio Health Group HMO |
$16,085.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,289.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,788.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,648.77
|
| Rate for Payer: PHCS Commercial |
$20,589.74
|
| Rate for Payer: United Healthcare All Payer |
$18,873.93
|
|
|
MBT POROUS TRAY SLEEVE 53MM
|
Facility
|
IP
|
$19,900.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,587.01 |
| Max. Negotiated Rate |
$19,104.05 |
| Rate for Payer: Aetna Commercial |
$15,323.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,522.04
|
| Rate for Payer: Cash Price |
$9,950.02
|
| Rate for Payer: Cigna Commercial |
$16,517.04
|
| Rate for Payer: First Health Commercial |
$18,905.05
|
| Rate for Payer: Humana Commercial |
$16,915.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,318.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,686.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,970.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,512.04
|
| Rate for Payer: Ohio Health Group HMO |
$14,925.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,980.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,587.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,169.02
|
| Rate for Payer: PHCS Commercial |
$19,104.05
|
| Rate for Payer: United Healthcare All Payer |
$17,512.04
|
|
|
MBT POROUS TRAY SLEEVE 53MM
|
Facility
|
OP
|
$19,900.05
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,587.01 |
| Max. Negotiated Rate |
$19,104.05 |
| Rate for Payer: Aetna Commercial |
$15,323.04
|
| Rate for Payer: Anthem Medicaid |
$6,843.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$15,522.04
|
| Rate for Payer: Cash Price |
$9,950.02
|
| Rate for Payer: Cigna Commercial |
$16,517.04
|
| Rate for Payer: First Health Commercial |
$18,905.05
|
| Rate for Payer: Humana Commercial |
$16,915.04
|
| Rate for Payer: Humana KY Medicaid |
$6,843.63
|
| Rate for Payer: Kentucky WC Medicaid |
$6,913.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$16,318.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$14,686.24
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,970.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$6,980.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$17,512.04
|
| Rate for Payer: Ohio Health Group HMO |
$14,925.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,980.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,587.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,169.02
|
| Rate for Payer: PHCS Commercial |
$19,104.05
|
| Rate for Payer: United Healthcare All Payer |
$17,512.04
|
|
|
MBT REV METAPHEAL POR SLV 29MM
|
Facility
|
IP
|
$21,811.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,835.43 |
| Max. Negotiated Rate |
$20,938.57 |
| Rate for Payer: Aetna Commercial |
$16,794.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,012.59
|
| Rate for Payer: Cash Price |
$10,905.50
|
| Rate for Payer: Cigna Commercial |
$18,103.14
|
| Rate for Payer: First Health Commercial |
$20,720.46
|
| Rate for Payer: Humana Commercial |
$18,539.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,885.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,096.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,543.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,193.69
|
| Rate for Payer: Ohio Health Group HMO |
$16,358.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,362.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,835.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,761.41
|
| Rate for Payer: PHCS Commercial |
$20,938.57
|
| Rate for Payer: United Healthcare All Payer |
$19,193.69
|
|
|
MBT REV METAPHEAL POR SLV 29MM
|
Facility
|
OP
|
$21,811.01
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,835.43 |
| Max. Negotiated Rate |
$20,938.57 |
| Rate for Payer: Aetna Commercial |
$16,794.48
|
| Rate for Payer: Anthem Medicaid |
$7,500.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,012.59
|
| Rate for Payer: Cash Price |
$10,905.50
|
| Rate for Payer: Cigna Commercial |
$18,103.14
|
| Rate for Payer: First Health Commercial |
$20,720.46
|
| Rate for Payer: Humana Commercial |
$18,539.36
|
| Rate for Payer: Humana KY Medicaid |
$7,500.81
|
| Rate for Payer: Kentucky WC Medicaid |
$7,577.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$17,885.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,096.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,543.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,651.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,193.69
|
| Rate for Payer: Ohio Health Group HMO |
$16,358.26
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,362.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,835.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,761.41
|
| Rate for Payer: PHCS Commercial |
$20,938.57
|
| Rate for Payer: United Healthcare All Payer |
$19,193.69
|
|
|
MBT STEP WEDGE SZ 1.5 10MM
|
Facility
|
OP
|
$16,126.80
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,096.48 |
| Max. Negotiated Rate |
$15,481.73 |
| Rate for Payer: Aetna Commercial |
$12,417.64
|
| Rate for Payer: Anthem Medicaid |
$5,546.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,578.90
|
| Rate for Payer: Cash Price |
$8,063.40
|
| Rate for Payer: Cigna Commercial |
$13,385.24
|
| Rate for Payer: First Health Commercial |
$15,320.46
|
| Rate for Payer: Humana Commercial |
$13,707.78
|
| Rate for Payer: Humana KY Medicaid |
$5,546.01
|
| Rate for Payer: Kentucky WC Medicaid |
$5,602.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,223.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,901.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,838.04
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,657.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,191.58
|
| Rate for Payer: Ohio Health Group HMO |
$12,095.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,225.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,096.48
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,999.31
|
| Rate for Payer: PHCS Commercial |
$15,481.73
|
| Rate for Payer: United Healthcare All Payer |
$14,191.58
|
|
