|
MTP FUSION SMALL 10 DEG L
|
Facility
|
IP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 10 DEG L
|
Facility
|
OP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem Medicaid |
$2,475.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Humana KY Medicaid |
$2,475.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,524.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 10 DEG R
|
Facility
|
OP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem Medicaid |
$2,475.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Humana KY Medicaid |
$2,475.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,524.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 10 DEG R
|
Facility
|
IP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 5 DEG L
|
Facility
|
OP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem Medicaid |
$2,475.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Humana KY Medicaid |
$2,475.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,524.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 5 DEG L
|
Facility
|
IP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 5 DEG R
|
Facility
|
IP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP FUSION SMALL 5 DEG R
|
Facility
|
OP
|
$7,197.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,159.25 |
| Max. Negotiated Rate |
$6,909.60 |
| Rate for Payer: Aetna Commercial |
$5,542.07
|
| Rate for Payer: Anthem Medicaid |
$2,475.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,614.05
|
| Rate for Payer: Cash Price |
$3,598.75
|
| Rate for Payer: Cigna Commercial |
$5,973.93
|
| Rate for Payer: First Health Commercial |
$6,837.62
|
| Rate for Payer: Humana Commercial |
$6,117.88
|
| Rate for Payer: Humana KY Medicaid |
$2,475.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,500.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,901.95
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,311.76
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,159.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,524.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,333.80
|
| Rate for Payer: Ohio Health Group HMO |
$5,398.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,758.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,261.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,966.27
|
| Rate for Payer: PHCS Commercial |
$6,909.60
|
| Rate for Payer: United Healthcare All Payer |
$6,333.80
|
|
|
MTP PLATE LARGE 5D 53 RIGHT
|
Facility
|
IP
|
$7,526.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,257.80 |
| Max. Negotiated Rate |
$7,224.96 |
| Rate for Payer: Aetna Commercial |
$5,795.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.28
|
| Rate for Payer: Cash Price |
$3,763.00
|
| Rate for Payer: Cigna Commercial |
$6,246.58
|
| Rate for Payer: First Health Commercial |
$7,149.70
|
| Rate for Payer: Humana Commercial |
$6,397.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,257.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,622.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,644.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,192.94
|
| Rate for Payer: PHCS Commercial |
$7,224.96
|
| Rate for Payer: United Healthcare All Payer |
$6,622.88
|
|
|
MTP PLATE LARGE 5D 53 RIGHT
|
Facility
|
OP
|
$7,526.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,257.80 |
| Max. Negotiated Rate |
$7,224.96 |
| Rate for Payer: Aetna Commercial |
$5,795.02
|
| Rate for Payer: Anthem Medicaid |
$2,588.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.28
|
| Rate for Payer: Cash Price |
$3,763.00
|
| Rate for Payer: Cigna Commercial |
$6,246.58
|
| Rate for Payer: First Health Commercial |
$7,149.70
|
| Rate for Payer: Humana Commercial |
$6,397.10
|
| Rate for Payer: Humana KY Medicaid |
$2,588.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,257.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,622.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,644.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,192.94
|
| Rate for Payer: PHCS Commercial |
$7,224.96
|
| Rate for Payer: United Healthcare All Payer |
$6,622.88
|
|
|
MTP PLATE LARGE 5D MPT53-10R
|
Facility
|
OP
|
$7,526.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,257.80 |
| Max. Negotiated Rate |
$7,224.96 |
| Rate for Payer: Aetna Commercial |
$5,795.02
|
| Rate for Payer: Anthem Medicaid |
$2,588.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.28
|
| Rate for Payer: Cash Price |
$3,763.00
|
| Rate for Payer: Cigna Commercial |
$6,246.58
|
| Rate for Payer: First Health Commercial |
$7,149.70
|
| Rate for Payer: Humana Commercial |
$6,397.10
|
| Rate for Payer: Humana KY Medicaid |
$2,588.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,257.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,622.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,644.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,192.94
|
| Rate for Payer: PHCS Commercial |
$7,224.96
|
| Rate for Payer: United Healthcare All Payer |
$6,622.88
|
|
|
MTP PLATE LARGE 5D MPT53-10R
|
Facility
|
IP
|
$7,526.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,257.80 |
| Max. Negotiated Rate |
$7,224.96 |
| Rate for Payer: Aetna Commercial |
$5,795.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.28
|
| Rate for Payer: Cash Price |
$3,763.00
|
| Rate for Payer: Cigna Commercial |
$6,246.58
|
| Rate for Payer: First Health Commercial |
$7,149.70
|
| Rate for Payer: Humana Commercial |
$6,397.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,257.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,622.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,644.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,192.94
|
| Rate for Payer: PHCS Commercial |
$7,224.96
|
| Rate for Payer: United Healthcare All Payer |
$6,622.88
|
|
|
MTP PLATE MEDIUM 0D 45 MM RIGH
|
Facility
|
OP
|
$7,526.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,257.80 |
| Max. Negotiated Rate |
$7,224.96 |
| Rate for Payer: Aetna Commercial |
$5,795.02
|
| Rate for Payer: Anthem Medicaid |
$2,588.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.28
|
| Rate for Payer: Cash Price |
$3,763.00
|
| Rate for Payer: Cigna Commercial |
$6,246.58
|
| Rate for Payer: First Health Commercial |
$7,149.70
|
| Rate for Payer: Humana Commercial |
$6,397.10
|
| Rate for Payer: Humana KY Medicaid |
$2,588.19
|
| Rate for Payer: Kentucky WC Medicaid |
$2,614.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,257.80
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,640.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,622.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,644.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,192.94
|
| Rate for Payer: PHCS Commercial |
$7,224.96
|
| Rate for Payer: United Healthcare All Payer |
$6,622.88
|
|
|
MTP PLATE MEDIUM 0D 45 MM RIGH
|
Facility
|
IP
|
$7,526.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,257.80 |
| Max. Negotiated Rate |
$7,224.96 |
| Rate for Payer: Aetna Commercial |
$5,795.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,870.28
|
| Rate for Payer: Cash Price |
$3,763.00
|
| Rate for Payer: Cigna Commercial |
$6,246.58
|
| Rate for Payer: First Health Commercial |
$7,149.70
|
| Rate for Payer: Humana Commercial |
$6,397.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,171.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,554.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,257.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,622.88
|
| Rate for Payer: Ohio Health Group HMO |
$5,644.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,020.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,547.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,192.94
|
| Rate for Payer: PHCS Commercial |
$7,224.96
|
| Rate for Payer: United Healthcare All Payer |
$6,622.88
|
|
|
MTR FUSION LEFT ACUMED
|
Facility
|
OP
|
$2,197.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$659.33 |
| Max. Negotiated Rate |
$2,109.84 |
| Rate for Payer: Aetna Commercial |
$1,692.27
|
| Rate for Payer: Anthem Medicaid |
$755.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,714.24
|
| Rate for Payer: Cash Price |
$1,098.88
|
| Rate for Payer: Cigna Commercial |
$1,824.13
|
| Rate for Payer: First Health Commercial |
$2,087.86
|
| Rate for Payer: Humana Commercial |
$1,868.09
|
| Rate for Payer: Humana KY Medicaid |
$755.81
|
| Rate for Payer: Kentucky WC Medicaid |
$763.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,802.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,621.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$659.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$770.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,934.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,648.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,758.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,912.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,516.45
|
| Rate for Payer: PHCS Commercial |
$2,109.84
|
| Rate for Payer: United Healthcare All Payer |
$1,934.02
|
|
|
MTR FUSION LEFT ACUMED
|
Facility
|
IP
|
$2,197.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$659.33 |
| Max. Negotiated Rate |
$2,109.84 |
| Rate for Payer: Aetna Commercial |
$1,692.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,714.24
|
| Rate for Payer: Cash Price |
$1,098.88
|
| Rate for Payer: Cigna Commercial |
$1,824.13
|
| Rate for Payer: First Health Commercial |
$2,087.86
|
| Rate for Payer: Humana Commercial |
$1,868.09
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,802.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,621.94
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$659.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,934.02
|
| Rate for Payer: Ohio Health Group HMO |
$1,648.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,758.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,912.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,516.45
|
| Rate for Payer: PHCS Commercial |
$2,109.84
|
| Rate for Payer: United Healthcare All Payer |
$1,934.02
|
|
|
MTX CEM 14/16 TPR SZ8S 8DD125L
|
Facility
|
IP
|
$13,622.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,086.83 |
| Max. Negotiated Rate |
$13,077.87 |
| Rate for Payer: Aetna Commercial |
$10,489.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,625.77
|
| Rate for Payer: Cash Price |
$6,811.39
|
| Rate for Payer: Cigna Commercial |
$11,306.91
|
| Rate for Payer: First Health Commercial |
$12,941.64
|
| Rate for Payer: Humana Commercial |
$11,579.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,170.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,053.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,086.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,988.05
|
| Rate for Payer: Ohio Health Group HMO |
$10,217.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,898.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,851.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,399.72
|
| Rate for Payer: PHCS Commercial |
$13,077.87
|
| Rate for Payer: United Healthcare All Payer |
$11,988.05
|
|
|
MTX CEM 14/16 TPR SZ8S 8DD125L
|
Facility
|
OP
|
$13,622.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,086.83 |
| Max. Negotiated Rate |
$13,077.87 |
| Rate for Payer: Aetna Commercial |
$10,489.54
|
| Rate for Payer: Anthem Medicaid |
$4,684.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,625.77
|
| Rate for Payer: Cash Price |
$6,811.39
|
| Rate for Payer: Cigna Commercial |
$11,306.91
|
| Rate for Payer: First Health Commercial |
$12,941.64
|
| Rate for Payer: Humana Commercial |
$11,579.36
|
| Rate for Payer: Humana KY Medicaid |
$4,684.87
|
| Rate for Payer: Kentucky WC Medicaid |
$4,732.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,170.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,053.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,086.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,778.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,988.05
|
| Rate for Payer: Ohio Health Group HMO |
$10,217.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,898.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,851.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,399.72
|
| Rate for Payer: PHCS Commercial |
$13,077.87
|
| Rate for Payer: United Healthcare All Payer |
$11,988.05
|
|
|
MTX CM 14/16 TPR 10S 10DD 135L
|
Facility
|
IP
|
$13,622.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,086.83 |
| Max. Negotiated Rate |
$13,077.87 |
| Rate for Payer: Aetna Commercial |
$10,489.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,625.77
|
| Rate for Payer: Cash Price |
$6,811.39
|
| Rate for Payer: Cigna Commercial |
$11,306.91
|
| Rate for Payer: First Health Commercial |
$12,941.64
|
| Rate for Payer: Humana Commercial |
$11,579.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,170.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,053.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,086.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,988.05
|
| Rate for Payer: Ohio Health Group HMO |
$10,217.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,898.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,851.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,399.72
|
| Rate for Payer: PHCS Commercial |
$13,077.87
|
| Rate for Payer: United Healthcare All Payer |
$11,988.05
|
|
|
MTX CM 14/16 TPR 10S 10DD 135L
|
Facility
|
OP
|
$13,622.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,086.83 |
| Max. Negotiated Rate |
$13,077.87 |
| Rate for Payer: Aetna Commercial |
$10,489.54
|
| Rate for Payer: Anthem Medicaid |
$4,684.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,625.77
|
| Rate for Payer: Cash Price |
$6,811.39
|
| Rate for Payer: Cigna Commercial |
$11,306.91
|
| Rate for Payer: First Health Commercial |
$12,941.64
|
| Rate for Payer: Humana Commercial |
$11,579.36
|
| Rate for Payer: Humana KY Medicaid |
$4,684.87
|
| Rate for Payer: Kentucky WC Medicaid |
$4,732.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,170.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,053.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,086.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,778.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,988.05
|
| Rate for Payer: Ohio Health Group HMO |
$10,217.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,898.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,851.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,399.72
|
| Rate for Payer: PHCS Commercial |
$13,077.87
|
| Rate for Payer: United Healthcare All Payer |
$11,988.05
|
|
|
MTX CM 14/16 TPR 14S 14DD 155L
|
Facility
|
IP
|
$13,622.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,086.83 |
| Max. Negotiated Rate |
$13,077.87 |
| Rate for Payer: Aetna Commercial |
$10,489.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,625.77
|
| Rate for Payer: Cash Price |
$6,811.39
|
| Rate for Payer: Cigna Commercial |
$11,306.91
|
| Rate for Payer: First Health Commercial |
$12,941.64
|
| Rate for Payer: Humana Commercial |
$11,579.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,170.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,053.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,086.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,988.05
|
| Rate for Payer: Ohio Health Group HMO |
$10,217.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,898.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,851.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,399.72
|
| Rate for Payer: PHCS Commercial |
$13,077.87
|
| Rate for Payer: United Healthcare All Payer |
$11,988.05
|
|
|
MTX CM 14/16 TPR 14S 14DD 155L
|
Facility
|
OP
|
$13,622.78
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,086.83 |
| Max. Negotiated Rate |
$13,077.87 |
| Rate for Payer: Aetna Commercial |
$10,489.54
|
| Rate for Payer: Anthem Medicaid |
$4,684.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,625.77
|
| Rate for Payer: Cash Price |
$6,811.39
|
| Rate for Payer: Cigna Commercial |
$11,306.91
|
| Rate for Payer: First Health Commercial |
$12,941.64
|
| Rate for Payer: Humana Commercial |
$11,579.36
|
| Rate for Payer: Humana KY Medicaid |
$4,684.87
|
| Rate for Payer: Kentucky WC Medicaid |
$4,732.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,170.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,053.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,086.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,778.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,988.05
|
| Rate for Payer: Ohio Health Group HMO |
$10,217.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,898.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,851.82
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$9,399.72
|
| Rate for Payer: PHCS Commercial |
$13,077.87
|
| Rate for Payer: United Healthcare All Payer |
$11,988.05
|
|
|
MUCINEX D TAB SR 12H
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 63824005736
|
| Hospital Charge Code |
25001016
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
MUCINEX D TAB SR 12H
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 63824005736
|
| Hospital Charge Code |
25001016
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.18
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.31
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
MUCINEX (GUAIFENESIN) 600 MG T
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 68084057201
|
| Hospital Charge Code |
25001015
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.84 |
| Rate for Payer: Aetna Commercial |
$3.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.93
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna Commercial |
$4.18
|
| Rate for Payer: First Health Commercial |
$4.79
|
| Rate for Payer: Humana Commercial |
$4.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.72
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.44
|
| Rate for Payer: Ohio Health Group HMO |
$3.78
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.48
|
| Rate for Payer: PHCS Commercial |
$4.84
|
| Rate for Payer: United Healthcare All Payer |
$4.44
|
|
