|
MIRENA 20 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
636T0071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.83
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
IP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
63600071
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA 20 MCG/24HR IUD
|
Facility
|
OP
|
$1,750.00
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$525.00 |
| Max. Negotiated Rate |
$1,680.00 |
| Rate for Payer: Aetna Commercial |
$1,347.50
|
| Rate for Payer: Anthem Medicaid |
$601.83
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,365.00
|
| Rate for Payer: Cash Price |
$875.00
|
| Rate for Payer: Cigna Commercial |
$1,452.50
|
| Rate for Payer: First Health Commercial |
$1,662.50
|
| Rate for Payer: Humana Commercial |
$1,487.50
|
| Rate for Payer: Humana KY Medicaid |
$601.83
|
| Rate for Payer: Kentucky WC Medicaid |
$607.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,435.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$525.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,540.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,400.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.50
|
| Rate for Payer: PHCS Commercial |
$1,680.00
|
| Rate for Payer: United Healthcare All Payer |
$1,540.00
|
|
|
MIRENA IUD
|
Facility
|
OP
|
$3,174.24
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$952.27 |
| Max. Negotiated Rate |
$3,047.27 |
| Rate for Payer: Aetna Commercial |
$2,444.16
|
| Rate for Payer: Anthem Medicaid |
$1,091.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,475.91
|
| Rate for Payer: Cash Price |
$1,587.12
|
| Rate for Payer: Cigna Commercial |
$2,634.62
|
| Rate for Payer: First Health Commercial |
$3,015.53
|
| Rate for Payer: Humana Commercial |
$2,698.10
|
| Rate for Payer: Humana KY Medicaid |
$1,091.62
|
| Rate for Payer: Kentucky WC Medicaid |
$1,102.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,602.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,342.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$952.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,113.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,793.33
|
| Rate for Payer: Ohio Health Group HMO |
$2,380.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,539.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,761.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,190.23
|
| Rate for Payer: PHCS Commercial |
$3,047.27
|
| Rate for Payer: United Healthcare All Payer |
$2,793.33
|
|
|
MIRENA IUD
|
Facility
|
IP
|
$3,174.24
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
25002483
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$952.27 |
| Max. Negotiated Rate |
$3,047.27 |
| Rate for Payer: Aetna Commercial |
$2,444.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,475.91
|
| Rate for Payer: Cash Price |
$1,587.12
|
| Rate for Payer: Cigna Commercial |
$2,634.62
|
| Rate for Payer: First Health Commercial |
$3,015.53
|
| Rate for Payer: Humana Commercial |
$2,698.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,602.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,342.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$952.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,793.33
|
| Rate for Payer: Ohio Health Group HMO |
$2,380.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,539.39
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,761.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,190.23
|
| Rate for Payer: PHCS Commercial |
$3,047.27
|
| Rate for Payer: United Healthcare All Payer |
$2,793.33
|
|
|
MISC SPECIAL ST GROUP I
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
HCPCS 88312
|
| Hospital Charge Code |
30001512
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.37 |
| Max. Negotiated Rate |
$243.84 |
| Rate for Payer: Aetna Commercial |
$195.58
|
| Rate for Payer: Anthem Medicaid |
$49.37
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$49.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.96
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$69.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$49.37
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cigna Commercial |
$210.82
|
| Rate for Payer: First Health Commercial |
$241.30
|
| Rate for Payer: Humana Commercial |
$215.90
|
| Rate for Payer: Humana KY Medicaid |
$49.37
|
| Rate for Payer: Humana Medicare Advantage |
$49.37
|
| Rate for Payer: Kentucky WC Medicaid |
$49.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$208.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$187.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$59.24
|
| Rate for Payer: Molina Healthcare Medicaid |
$50.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$223.52
|
| Rate for Payer: Ohio Health Group HMO |
$190.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$220.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.26
|
| Rate for Payer: PHCS Commercial |
$243.84
|
| Rate for Payer: United Healthcare All Payer |
$223.52
|
|
|
MISC SPECIAL ST GROUP I
|
Professional
|
Both
|
$254.00
|
|
|
Service Code
|
HCPCS 88312
|
| Hospital Charge Code |
30001512
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.98 |
| Max. Negotiated Rate |
$152.40 |
| Rate for Payer: Aetna Commercial |
$147.85
|
| Rate for Payer: Ambetter Exchange |
$100.39
|
| Rate for Payer: Buckeye Individual/Medicaid |
$100.39
|
| Rate for Payer: Buckeye Medicare Advantage |
$100.39
|
| Rate for Payer: CareSource Just4Me Medicare |
$120.47
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cigna Commercial |
$55.51
|
| Rate for Payer: Healthspan PPO |
$140.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$13.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$100.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$100.39
|
| Rate for Payer: Multiplan PHCS |
$152.40
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$130.51
|
| Rate for Payer: UHCCP Medicaid |
$88.90
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$42.62
|
| Rate for Payer: Wellcare Medicare Advantage |
$100.39
|
|
|
MISC SPECIAL ST GROUP I
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
HCPCS 88312
|
| Hospital Charge Code |
30001512
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$76.20 |
| Max. Negotiated Rate |
$243.84 |
| Rate for Payer: Aetna Commercial |
$195.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$203.96
|
| Rate for Payer: Cash Price |
$127.00
|
| Rate for Payer: Cigna Commercial |
$210.82
|
| Rate for Payer: First Health Commercial |
$241.30
|
| Rate for Payer: Humana Commercial |
$215.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$208.28
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$187.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$76.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$223.52
|
| Rate for Payer: Ohio Health Group HMO |
$190.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$203.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$220.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$175.26
|
| Rate for Payer: PHCS Commercial |
$243.84
|
| Rate for Payer: United Healthcare All Payer |
$223.52
|
|
|
MIS TRAB METAL MOD TIB PLT SZ2
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ2
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ3
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ3
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ4
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ4
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ5
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ5
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ6
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ6
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ7
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ7
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ8
|
Facility
|
IP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
MIS TRAB METAL MOD TIB PLT SZ8
|
Facility
|
OP
|
$11,867.60
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,560.28 |
| Max. Negotiated Rate |
$11,392.90 |
| Rate for Payer: Aetna Commercial |
$9,138.05
|
| Rate for Payer: Anthem Medicaid |
$4,081.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,256.73
|
| Rate for Payer: Cash Price |
$5,933.80
|
| Rate for Payer: Cigna Commercial |
$9,850.11
|
| Rate for Payer: First Health Commercial |
$11,274.22
|
| Rate for Payer: Humana Commercial |
$10,087.46
|
| Rate for Payer: Humana KY Medicaid |
$4,081.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,122.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,731.43
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,758.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,560.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,163.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,443.49
|
| Rate for Payer: Ohio Health Group HMO |
$8,900.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,494.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,324.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,188.64
|
| Rate for Payer: PHCS Commercial |
$11,392.90
|
| Rate for Payer: United Healthcare All Payer |
$10,443.49
|
|
|
Mitomycin 0.1mg/mL EYE (Drop)
|
Facility
|
IP
|
$86.65
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$83.18 |
| Rate for Payer: Aetna Commercial |
$66.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.59
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cigna Commercial |
$71.92
|
| Rate for Payer: First Health Commercial |
$82.32
|
| Rate for Payer: Humana Commercial |
$73.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.25
|
| Rate for Payer: Ohio Health Group HMO |
$64.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.79
|
| Rate for Payer: PHCS Commercial |
$83.18
|
| Rate for Payer: United Healthcare All Payer |
$76.25
|
|
|
Mitomycin 0.1mg/mL EYE (Drop)
|
Facility
|
OP
|
$86.65
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004052
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.27 |
| Max. Negotiated Rate |
$83.18 |
| Rate for Payer: Aetna Commercial |
$66.72
|
| Rate for Payer: Anthem Medicaid |
$29.80
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$28.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$67.59
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$39.58
|
| Rate for Payer: CareSource Just4Me Medicare |
$38.16
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cigna Commercial |
$71.92
|
| Rate for Payer: First Health Commercial |
$82.32
|
| Rate for Payer: Humana Commercial |
$73.65
|
| Rate for Payer: Humana KY Medicaid |
$29.80
|
| Rate for Payer: Humana Medicare Advantage |
$28.27
|
| Rate for Payer: Kentucky WC Medicaid |
$30.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$71.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$63.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.92
|
| Rate for Payer: Molina Healthcare Medicaid |
$30.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$76.25
|
| Rate for Payer: Ohio Health Group HMO |
$64.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$69.32
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$75.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$59.79
|
| Rate for Payer: PHCS Commercial |
$83.18
|
| Rate for Payer: United Healthcare All Payer |
$76.25
|
|
|
MITOMYCIN 5MG(40MG SDV)BLADDER
|
Facility
|
IP
|
$6,888.58
|
|
|
Service Code
|
HCPCS J9280
|
| Hospital Charge Code |
25004259
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,066.57 |
| Max. Negotiated Rate |
$6,613.04 |
| Rate for Payer: Aetna Commercial |
$5,304.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,373.09
|
| Rate for Payer: Cash Price |
$3,444.29
|
| Rate for Payer: Cigna Commercial |
$5,717.52
|
| Rate for Payer: First Health Commercial |
$6,544.15
|
| Rate for Payer: Humana Commercial |
$5,855.29
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,648.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,083.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,066.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,061.95
|
| Rate for Payer: Ohio Health Group HMO |
$5,166.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,510.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,993.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,753.12
|
| Rate for Payer: PHCS Commercial |
$6,613.04
|
| Rate for Payer: United Healthcare All Payer |
$6,061.95
|
|
