|
MEMO 3D SEMI RGD ANNUL RING 24
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 26
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 26
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 28
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 28
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 30
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 30
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 32
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 32
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 34
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 34
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 36
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 36
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 38
|
Facility
|
OP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem Medicaid |
$3,229.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Humana KY Medicaid |
$3,229.62
|
| Rate for Payer: Kentucky WC Medicaid |
$3,262.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,294.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MEMO 3D SEMI RGD ANNUL RING 38
|
Facility
|
IP
|
$9,391.15
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,817.34 |
| Max. Negotiated Rate |
$9,015.50 |
| Rate for Payer: Aetna Commercial |
$7,231.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,325.10
|
| Rate for Payer: Cash Price |
$4,695.58
|
| Rate for Payer: Cigna Commercial |
$7,794.65
|
| Rate for Payer: First Health Commercial |
$8,921.59
|
| Rate for Payer: Humana Commercial |
$7,982.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,700.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,930.67
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,817.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,264.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,043.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,512.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,170.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,479.89
|
| Rate for Payer: PHCS Commercial |
$9,015.50
|
| Rate for Payer: United Healthcare All Payer |
$8,264.21
|
|
|
MENACWY-TT VACCINE IM
|
Professional
|
Both
|
$599.22
|
|
|
Service Code
|
HCPCS 90619
|
| Hospital Charge Code |
63600261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.00 |
| Max. Negotiated Rate |
$419.45 |
| Rate for Payer: Anthem Medicaid |
$82.00
|
| Rate for Payer: Cash Price |
$299.61
|
| Rate for Payer: Cash Price |
$299.61
|
| Rate for Payer: Humana Medicaid |
$82.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$240.47
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$83.64
|
| Rate for Payer: Molina Healthcare Passport |
$82.00
|
| Rate for Payer: Multiplan PHCS |
$359.53
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$419.45
|
| Rate for Payer: UHCCP Medicaid |
$209.73
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$82.82
|
|
|
MENACWY-TT VACCINE IM
|
Facility
|
OP
|
$599.22
|
|
|
Service Code
|
HCPCS 90619
|
| Hospital Charge Code |
63600261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.77 |
| Max. Negotiated Rate |
$575.25 |
| Rate for Payer: Aetna Commercial |
$461.40
|
| Rate for Payer: Anthem Medicaid |
$206.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$467.39
|
| Rate for Payer: Cash Price |
$299.61
|
| Rate for Payer: Cigna Commercial |
$497.35
|
| Rate for Payer: First Health Commercial |
$569.26
|
| Rate for Payer: Humana Commercial |
$509.34
|
| Rate for Payer: Humana KY Medicaid |
$206.07
|
| Rate for Payer: Kentucky WC Medicaid |
$208.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$491.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$179.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$527.31
|
| Rate for Payer: Ohio Health Group HMO |
$449.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$479.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$413.46
|
| Rate for Payer: PHCS Commercial |
$575.25
|
| Rate for Payer: United Healthcare All Payer |
$527.31
|
|
|
MENACWY-TT VACCINE IM
|
Facility
|
IP
|
$599.22
|
|
|
Service Code
|
HCPCS 90619
|
| Hospital Charge Code |
63600261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.77 |
| Max. Negotiated Rate |
$575.25 |
| Rate for Payer: Aetna Commercial |
$461.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$467.39
|
| Rate for Payer: Cash Price |
$299.61
|
| Rate for Payer: Cigna Commercial |
$497.35
|
| Rate for Payer: First Health Commercial |
$569.26
|
| Rate for Payer: Humana Commercial |
$509.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$491.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$179.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$527.31
|
| Rate for Payer: Ohio Health Group HMO |
$449.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$479.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$413.46
|
| Rate for Payer: PHCS Commercial |
$575.25
|
| Rate for Payer: United Healthcare All Payer |
$527.31
|
|
|
MENACWY-TT VACCINE IM (T
|
Facility
|
IP
|
$599.22
|
|
|
Service Code
|
HCPCS 90619
|
| Hospital Charge Code |
636T0261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.77 |
| Max. Negotiated Rate |
$575.25 |
| Rate for Payer: Aetna Commercial |
$461.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$467.39
|
| Rate for Payer: Cash Price |
$299.61
|
| Rate for Payer: Cigna Commercial |
$497.35
|
| Rate for Payer: First Health Commercial |
$569.26
|
| Rate for Payer: Humana Commercial |
$509.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$491.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$179.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$527.31
|
| Rate for Payer: Ohio Health Group HMO |
$449.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$479.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$413.46
|
| Rate for Payer: PHCS Commercial |
$575.25
|
| Rate for Payer: United Healthcare All Payer |
$527.31
|
|
|
MENACWY-TT VACCINE IM (T
|
Facility
|
OP
|
$599.22
|
|
|
Service Code
|
HCPCS 90619
|
| Hospital Charge Code |
636T0261
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$179.77 |
| Max. Negotiated Rate |
$575.25 |
| Rate for Payer: Aetna Commercial |
$461.40
|
| Rate for Payer: Anthem Medicaid |
$206.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$467.39
|
| Rate for Payer: Cash Price |
$299.61
|
| Rate for Payer: Cigna Commercial |
$497.35
|
| Rate for Payer: First Health Commercial |
$569.26
|
| Rate for Payer: Humana Commercial |
$509.34
|
| Rate for Payer: Humana KY Medicaid |
$206.07
|
| Rate for Payer: Kentucky WC Medicaid |
$208.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$491.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$442.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$179.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$210.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$527.31
|
| Rate for Payer: Ohio Health Group HMO |
$449.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$479.38
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$521.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$413.46
|
| Rate for Payer: PHCS Commercial |
$575.25
|
| Rate for Payer: United Healthcare All Payer |
$527.31
|
|
|
MENB-4C BEXSERO
|
Facility
|
IP
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
77000088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$244.63 |
| 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 |
$652.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.65
|
| 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 |
770T0088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$244.63 |
| 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 |
$652.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.65
|
| 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 |
770T0088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$244.63 |
| 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 |
$652.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.65
|
| 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 |
$122.95 |
| Max. Negotiated Rate |
$570.81 |
| Rate for Payer: Anthem Medicaid |
$122.95
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Cash Price |
$407.72
|
| Rate for Payer: Humana Medicaid |
$122.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$326.08
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$125.41
|
| Rate for Payer: Molina Healthcare Passport |
$122.95
|
| 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
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$124.18
|
|
|
MENB-4C BEXSERO
|
Facility
|
OP
|
$815.44
|
|
|
Service Code
|
HCPCS 90620
|
| Hospital Charge Code |
77000088
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$244.63 |
| 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 |
$652.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$709.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$562.65
|
| Rate for Payer: PHCS Commercial |
$782.82
|
| Rate for Payer: United Healthcare All Payer |
$717.59
|
|
