|
MEMO 3D SEMI RGD ANNUL RING 26
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 26
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 28
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 28
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 30
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 30
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 32
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 32
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 34
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 34
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 36
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 36
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 38
|
Facility
|
IP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 38
|
Facility
|
OP
|
$9,191.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,194.85 |
| Max. Negotiated Rate |
$8,823.50 |
| Rate for Payer: Aetna Commercial |
$7,077.19
|
| Rate for Payer: Anthem Medicaid |
$3,160.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,169.10
|
| Rate for Payer: Cash Price |
$4,595.58
|
| Rate for Payer: Cigna Commercial |
$7,628.65
|
| Rate for Payer: First Health Commercial |
$8,731.59
|
| Rate for Payer: Humana Commercial |
$7,812.48
|
| Rate for Payer: Humana KY Medicaid |
$3,160.84
|
| Rate for Payer: Kentucky WC Medicaid |
$3,193.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,536.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,783.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,757.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,224.26
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,088.21
|
| Rate for Payer: Ohio Health Group HMO |
$6,893.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,838.23
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,194.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,849.26
|
| Rate for Payer: PHCS Commercial |
$8,823.50
|
| Rate for Payer: United Healthcare All Payer |
$8,088.21
|
|
|
MENB-4C BEXSERO
|
Facility
|
IP
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
770T0088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.01 |
| Max. Negotiated Rate |
$782.82 |
| Rate for Payer: Aetna Commercial |
$627.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.04
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Cigna Commercial |
$676.82
|
| Rate for Payer: First Health Commercial |
$774.67
|
| Rate for Payer: Humana Commercial |
$693.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.59
|
| Rate for Payer: Ohio Health Group HMO |
$611.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.79
|
| Rate for Payer: PHCS Commercial |
$782.82
|
| Rate for Payer: United Healthcare All Payer |
$717.59
|
|
|
MENB-4C BEXSERO
|
Facility
|
IP
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
77000088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.01 |
| Max. Negotiated Rate |
$782.82 |
| Rate for Payer: Aetna Commercial |
$627.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.04
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Cigna Commercial |
$676.82
|
| Rate for Payer: First Health Commercial |
$774.67
|
| Rate for Payer: Humana Commercial |
$693.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.59
|
| Rate for Payer: Ohio Health Group HMO |
$611.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.79
|
| Rate for Payer: PHCS Commercial |
$782.82
|
| Rate for Payer: United Healthcare All Payer |
$717.59
|
|
|
MENB-4C BEXSERO
|
Facility
|
OP
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
77000088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.01 |
| Max. Negotiated Rate |
$782.82 |
| Rate for Payer: Aetna Commercial |
$627.89
|
| Rate for Payer: Anthem Medicaid |
$280.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.04
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Cigna Commercial |
$676.82
|
| Rate for Payer: First Health Commercial |
$774.67
|
| Rate for Payer: Humana Commercial |
$693.12
|
| Rate for Payer: Humana KY Medicaid |
$280.43
|
| Rate for Payer: Kentucky WC Medicaid |
$283.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$286.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.59
|
| Rate for Payer: Ohio Health Group HMO |
$611.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.79
|
| Rate for Payer: PHCS Commercial |
$782.82
|
| Rate for Payer: United Healthcare All Payer |
$717.59
|
|
|
MENB-4C BEXSERO
|
Professional
|
Both
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
77000088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$285.40 |
| Max. Negotiated Rate |
$815.44 |
| Rate for Payer: Buckeye Medicare Advantage |
$815.44
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$326.08
|
| Rate for Payer: Multiplan PHCS |
$489.26
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$570.81
|
| Rate for Payer: UHCCP Medicaid |
$285.40
|
|
|
MENB-4C BEXSERO
|
Facility
|
OP
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
770T0088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$106.01 |
| Max. Negotiated Rate |
$782.82 |
| Rate for Payer: Aetna Commercial |
$627.89
|
| Rate for Payer: Anthem Medicaid |
$280.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$636.04
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Cigna Commercial |
$676.82
|
| Rate for Payer: First Health Commercial |
$774.67
|
| Rate for Payer: Humana Commercial |
$693.12
|
| Rate for Payer: Humana KY Medicaid |
$280.43
|
| Rate for Payer: Kentucky WC Medicaid |
$283.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$668.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$601.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$244.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$286.06
|
| Rate for Payer: Ohio Health Choice Commercial |
$717.59
|
| Rate for Payer: Ohio Health Group HMO |
$611.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$163.09
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$106.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$252.79
|
| Rate for Payer: PHCS Commercial |
$782.82
|
| Rate for Payer: United Healthcare All Payer |
$717.59
|
|
|
MENB-FHBP VACC 2/3 DOSE IM
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
77000009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
MENB-FHBP VACC 2/3 DOSE IM
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
77000009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
MENB-FHBP VACC 2/3 DOSE IM
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
77000009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$213.50 |
| Max. Negotiated Rate |
$610.00 |
| Rate for Payer: Buckeye Medicare Advantage |
$610.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$267.55
|
| Rate for Payer: Multiplan PHCS |
$366.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$427.00
|
| Rate for Payer: UHCCP Medicaid |
$213.50
|
|
|
MENB-FHBP VACC 2/3 DOSE IM(T
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
770T0009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
MENB-FHBP VACC 2/3 DOSE IM(T
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 90621
|
| Hospital Charge Code |
770T0009
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$122.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$79.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$189.10
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
MENEST 0.625MG TABLET
|
Facility
|
IP
|
$10.66
|
|
|
Service Code
|
NDC 61570007301
|
| Hospital Charge Code |
25000960
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$10.23 |
| Rate for Payer: Aetna Commercial |
$8.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.31
|
| Rate for Payer: Cash Price |
$5.33
|
| Rate for Payer: Cigna Commercial |
$8.85
|
| Rate for Payer: First Health Commercial |
$10.13
|
| Rate for Payer: Humana Commercial |
$9.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.87
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.38
|
| Rate for Payer: Ohio Health Group HMO |
$8.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.13
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.30
|
| Rate for Payer: PHCS Commercial |
$10.23
|
| Rate for Payer: United Healthcare All Payer |
$9.38
|
|
