|
OMM 9-10 BODY REGIONS
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
45000318
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$57.60 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
OMM 9-10 BODY REGIONS
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
45000318
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$46.20
|
| Rate for Payer: Anthem Medicaid |
$20.63
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$46.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.29
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna Commercial |
$49.80
|
| Rate for Payer: First Health Commercial |
$57.00
|
| Rate for Payer: Humana Commercial |
$51.00
|
| Rate for Payer: Humana KY Medicaid |
$20.63
|
| Rate for Payer: Humana Medicare Advantage |
$22.44
|
| Rate for Payer: Kentucky WC Medicaid |
$20.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$49.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$44.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,200.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$52.80
|
| Rate for Payer: Ohio Health Group HMO |
$45.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$12.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.60
|
| Rate for Payer: PHCS Commercial |
$57.60
|
| Rate for Payer: United Healthcare All Payer |
$52.80
|
|
|
OMM 9-10 BODY REGIONS
|
Facility
|
OP
|
$58.00
|
|
|
Service Code
|
HCPCS 98929
|
| Hospital Charge Code |
76102510
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$7.54 |
| Max. Negotiated Rate |
$55.68 |
| Rate for Payer: Aetna Commercial |
$44.66
|
| Rate for Payer: Anthem Medicaid |
$19.95
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$22.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$45.24
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$31.42
|
| Rate for Payer: CareSource Just4Me Medicare |
$30.29
|
| Rate for Payer: Cash Price |
$29.00
|
| Rate for Payer: Cash Price |
$29.00
|
| Rate for Payer: Cigna Commercial |
$48.14
|
| Rate for Payer: First Health Commercial |
$55.10
|
| Rate for Payer: Humana Commercial |
$49.30
|
| Rate for Payer: Humana KY Medicaid |
$19.95
|
| Rate for Payer: Humana Medicare Advantage |
$22.44
|
| Rate for Payer: Kentucky WC Medicaid |
$20.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$47.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$42.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$26.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$51.04
|
| Rate for Payer: Ohio Health Group HMO |
$43.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$11.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$17.98
|
| Rate for Payer: PHCS Commercial |
$55.68
|
| Rate for Payer: United Healthcare All Payer |
$51.04
|
|
|
OMNI CATH 120CM
|
Facility
|
IP
|
$8,658.25
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,125.57 |
| Max. Negotiated Rate |
$8,311.92 |
| Rate for Payer: Aetna Commercial |
$6,666.85
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,753.44
|
| Rate for Payer: Cash Price |
$4,329.12
|
| Rate for Payer: Cigna Commercial |
$7,186.35
|
| Rate for Payer: First Health Commercial |
$8,225.34
|
| Rate for Payer: Humana Commercial |
$7,359.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,099.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,389.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,597.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,619.26
|
| Rate for Payer: Ohio Health Group HMO |
$6,493.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,731.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,125.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.06
|
| Rate for Payer: PHCS Commercial |
$8,311.92
|
| Rate for Payer: United Healthcare All Payer |
$7,619.26
|
|
|
OMNI CATH 120CM
|
Facility
|
OP
|
$8,658.25
|
|
|
Service Code
|
HCPCS C1757
|
| Hospital Charge Code |
27000008
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,125.57 |
| Max. Negotiated Rate |
$8,311.92 |
| Rate for Payer: First Health Commercial |
$8,225.34
|
| Rate for Payer: Humana Commercial |
$7,359.51
|
| Rate for Payer: Humana KY Medicaid |
$2,977.57
|
| Rate for Payer: Kentucky WC Medicaid |
$3,007.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,099.76
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,389.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,597.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,037.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,619.26
|
| Rate for Payer: Ohio Health Group HMO |
$6,493.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,731.65
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,125.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,684.06
|
| Rate for Payer: PHCS Commercial |
$8,311.92
|
| Rate for Payer: United Healthcare All Payer |
$7,619.26
|
| Rate for Payer: Aetna Commercial |
$6,666.85
|
| Rate for Payer: Anthem Medicaid |
$2,977.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,753.44
|
| Rate for Payer: Cash Price |
$4,329.12
|
| Rate for Payer: Cigna Commercial |
$7,186.35
|
|
|
OMNICEF 250MG 5ML SUSP 60ML
|
Facility
|
IP
|
$9.67
|
|
|
Service Code
|
NDC 68180072304
|
| Hospital Charge Code |
25001125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
|
|
OMNICEF 250MG 5ML SUSP 60ML
|
Facility
|
OP
|
$9.67
|
|
|
Service Code
|
NDC 68180072304
|
| Hospital Charge Code |
25001125
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Aetna Commercial |
$7.45
|
| Rate for Payer: Anthem Medicaid |
$3.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.54
|
| Rate for Payer: Cash Price |
$4.84
|
| Rate for Payer: Cigna Commercial |
$8.03
|
| Rate for Payer: First Health Commercial |
$9.19
|
| Rate for Payer: Humana Commercial |
$8.22
|
| Rate for Payer: Humana KY Medicaid |
$3.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3.36
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.51
|
| Rate for Payer: Ohio Health Group HMO |
$7.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.00
|
| Rate for Payer: PHCS Commercial |
$9.28
|
| Rate for Payer: United Healthcare All Payer |
$8.51
|
|
|
OMNICEFCEFDINIR125MG/5ML60MLSU
|
Facility
|
OP
|
$9.25
|
|
|
Service Code
|
NDC 68180072205
|
| Hospital Charge Code |
25001126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Aetna Commercial |
$7.12
|
| Rate for Payer: Anthem Medicaid |
$3.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.22
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cigna Commercial |
$7.68
|
| Rate for Payer: First Health Commercial |
$8.79
|
| Rate for Payer: Humana Commercial |
$7.86
|
| Rate for Payer: Humana KY Medicaid |
$3.18
|
| Rate for Payer: Kentucky WC Medicaid |
$3.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.14
|
| Rate for Payer: Ohio Health Group HMO |
$6.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Payer |
$8.14
|
|
|
OMNICEFCEFDINIR125MG/5ML60MLSU
|
Facility
|
IP
|
$9.25
|
|
|
Service Code
|
NDC 68180072205
|
| Hospital Charge Code |
25001126
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.88 |
| Rate for Payer: Aetna Commercial |
$7.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.22
|
| Rate for Payer: Cash Price |
$4.62
|
| Rate for Payer: Cigna Commercial |
$7.68
|
| Rate for Payer: First Health Commercial |
$8.79
|
| Rate for Payer: Humana Commercial |
$7.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.58
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.83
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.14
|
| Rate for Payer: Ohio Health Group HMO |
$6.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.87
|
| Rate for Payer: PHCS Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Payer |
$8.14
|
|
|
OMNICEF (CEFDINIR) 300MG CAP
|
Facility
|
OP
|
$9.21
|
|
|
Service Code
|
NDC 68001036206
|
| Hospital Charge Code |
25003312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.84 |
| Rate for Payer: Aetna Commercial |
$7.09
|
| Rate for Payer: Anthem Medicaid |
$3.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.18
|
| Rate for Payer: Cash Price |
$4.61
|
| Rate for Payer: Cigna Commercial |
$7.64
|
| Rate for Payer: First Health Commercial |
$8.75
|
| Rate for Payer: Humana Commercial |
$7.83
|
| Rate for Payer: Humana KY Medicaid |
$3.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.10
|
| Rate for Payer: Ohio Health Group HMO |
$6.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.86
|
| Rate for Payer: PHCS Commercial |
$8.84
|
| Rate for Payer: United Healthcare All Payer |
$8.10
|
|
|
OMNICEF (CEFDINIR) 300MG CAP
|
Facility
|
IP
|
$9.21
|
|
|
Service Code
|
NDC 68001036206
|
| Hospital Charge Code |
25003312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$8.84 |
| Rate for Payer: Aetna Commercial |
$7.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.18
|
| Rate for Payer: Cash Price |
$4.61
|
| Rate for Payer: Cigna Commercial |
$7.64
|
| Rate for Payer: First Health Commercial |
$8.75
|
| Rate for Payer: Humana Commercial |
$7.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.76
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.10
|
| Rate for Payer: Ohio Health Group HMO |
$6.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.20
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.86
|
| Rate for Payer: PHCS Commercial |
$8.84
|
| Rate for Payer: United Healthcare All Payer |
$8.10
|
|
|
OMNIFIT CEMENT SPACERS 10MM
|
Facility
|
IP
|
$1,889.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.57 |
| Max. Negotiated Rate |
$1,813.44 |
| Rate for Payer: Aetna Commercial |
$1,454.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,473.42
|
| Rate for Payer: Cash Price |
$944.50
|
| Rate for Payer: Cigna Commercial |
$1,567.87
|
| Rate for Payer: First Health Commercial |
$1,794.55
|
| Rate for Payer: Humana Commercial |
$1,605.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,394.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,662.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$377.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$245.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.59
|
| Rate for Payer: PHCS Commercial |
$1,813.44
|
| Rate for Payer: United Healthcare All Payer |
$1,662.32
|
|
|
OMNIFIT CEMENT SPACERS 10MM
|
Facility
|
OP
|
$1,889.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$245.57 |
| Max. Negotiated Rate |
$1,813.44 |
| Rate for Payer: Aetna Commercial |
$1,454.53
|
| Rate for Payer: Anthem Medicaid |
$649.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,473.42
|
| Rate for Payer: Cash Price |
$944.50
|
| Rate for Payer: Cigna Commercial |
$1,567.87
|
| Rate for Payer: First Health Commercial |
$1,794.55
|
| Rate for Payer: Humana Commercial |
$1,605.65
|
| Rate for Payer: Humana KY Medicaid |
$649.63
|
| Rate for Payer: Kentucky WC Medicaid |
$656.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,548.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,394.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$566.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$662.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,662.32
|
| Rate for Payer: Ohio Health Group HMO |
$1,416.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$377.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$245.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$585.59
|
| Rate for Payer: PHCS Commercial |
$1,813.44
|
| Rate for Payer: United Healthcare All Payer |
$1,662.32
|
|
|
OMNIFIT CEMENT SPACERS 11M
|
Facility
|
OP
|
$1,869.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$243.02 |
| Max. Negotiated Rate |
$1,794.62 |
| Rate for Payer: Aetna Commercial |
$1,439.44
|
| Rate for Payer: Anthem Medicaid |
$642.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.13
|
| Rate for Payer: Cash Price |
$934.70
|
| Rate for Payer: Cigna Commercial |
$1,551.60
|
| Rate for Payer: First Health Commercial |
$1,775.93
|
| Rate for Payer: Humana Commercial |
$1,588.99
|
| Rate for Payer: Humana KY Medicaid |
$642.89
|
| Rate for Payer: Kentucky WC Medicaid |
$649.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,532.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,379.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$560.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$655.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.07
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$373.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$579.51
|
| Rate for Payer: PHCS Commercial |
$1,794.62
|
| Rate for Payer: United Healthcare All Payer |
$1,645.07
|
|
|
OMNIFIT CEMENT SPACERS 11M
|
Facility
|
IP
|
$1,869.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$243.02 |
| Max. Negotiated Rate |
$1,794.62 |
| Rate for Payer: Aetna Commercial |
$1,439.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,458.13
|
| Rate for Payer: Cash Price |
$934.70
|
| Rate for Payer: Cigna Commercial |
$1,551.60
|
| Rate for Payer: First Health Commercial |
$1,775.93
|
| Rate for Payer: Humana Commercial |
$1,588.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,532.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,379.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$560.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,645.07
|
| Rate for Payer: Ohio Health Group HMO |
$1,402.05
|
| Rate for Payer: Ohio Health Group PPO Differential |
$373.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$243.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$579.51
|
| Rate for Payer: PHCS Commercial |
$1,794.62
|
| Rate for Payer: United Healthcare All Payer |
$1,645.07
|
|
|
OMNIFIT CEMENT SPACERS 12MM
|
Facility
|
IP
|
$1,778.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$1,707.26 |
| Rate for Payer: Aetna Commercial |
$1,369.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,387.15
|
| Rate for Payer: Cash Price |
$889.20
|
| Rate for Payer: Cigna Commercial |
$1,476.07
|
| Rate for Payer: First Health Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial |
$1,511.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,458.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,312.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$533.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,564.99
|
| Rate for Payer: Ohio Health Group HMO |
$1,333.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.30
|
| Rate for Payer: PHCS Commercial |
$1,707.26
|
| Rate for Payer: United Healthcare All Payer |
$1,564.99
|
|
|
OMNIFIT CEMENT SPACERS 12MM
|
Facility
|
OP
|
$1,778.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$1,707.26 |
| Rate for Payer: Aetna Commercial |
$1,369.37
|
| Rate for Payer: Anthem Medicaid |
$611.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,387.15
|
| Rate for Payer: Cash Price |
$889.20
|
| Rate for Payer: Cigna Commercial |
$1,476.07
|
| Rate for Payer: First Health Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial |
$1,511.64
|
| Rate for Payer: Humana KY Medicaid |
$611.59
|
| Rate for Payer: Kentucky WC Medicaid |
$617.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,458.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,312.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$533.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$623.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,564.99
|
| Rate for Payer: Ohio Health Group HMO |
$1,333.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.30
|
| Rate for Payer: PHCS Commercial |
$1,707.26
|
| Rate for Payer: United Healthcare All Payer |
$1,564.99
|
|
|
OMNIFIT CEMENT SPACERS 13MM
|
Facility
|
IP
|
$1,764.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.37 |
| Max. Negotiated Rate |
$1,693.82 |
| Rate for Payer: Aetna Commercial |
$1,358.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.23
|
| Rate for Payer: Cash Price |
$882.20
|
| Rate for Payer: Cigna Commercial |
$1,464.45
|
| Rate for Payer: First Health Commercial |
$1,676.18
|
| Rate for Payer: Humana Commercial |
$1,499.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,446.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,552.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$546.96
|
| Rate for Payer: PHCS Commercial |
$1,693.82
|
| Rate for Payer: United Healthcare All Payer |
$1,552.67
|
|
|
OMNIFIT CEMENT SPACERS 13MM
|
Facility
|
OP
|
$1,764.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$229.37 |
| Max. Negotiated Rate |
$1,693.82 |
| Rate for Payer: Aetna Commercial |
$1,358.59
|
| Rate for Payer: Anthem Medicaid |
$606.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.23
|
| Rate for Payer: Cash Price |
$882.20
|
| Rate for Payer: Cigna Commercial |
$1,464.45
|
| Rate for Payer: First Health Commercial |
$1,676.18
|
| Rate for Payer: Humana Commercial |
$1,499.74
|
| Rate for Payer: Humana KY Medicaid |
$606.78
|
| Rate for Payer: Kentucky WC Medicaid |
$612.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,446.81
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.13
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$618.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,552.67
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.30
|
| Rate for Payer: Ohio Health Group PPO Differential |
$352.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$229.37
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$546.96
|
| Rate for Payer: PHCS Commercial |
$1,693.82
|
| Rate for Payer: United Healthcare All Payer |
$1,552.67
|
|
|
OMNIFIT CEMENT SPACERS 14MM
|
Facility
|
OP
|
$1,778.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$1,707.26 |
| Rate for Payer: Aetna Commercial |
$1,369.37
|
| Rate for Payer: Anthem Medicaid |
$611.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,387.15
|
| Rate for Payer: Cash Price |
$889.20
|
| Rate for Payer: Cigna Commercial |
$1,476.07
|
| Rate for Payer: First Health Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial |
$1,511.64
|
| Rate for Payer: Humana KY Medicaid |
$611.59
|
| Rate for Payer: Kentucky WC Medicaid |
$617.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,458.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,312.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$533.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$623.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,564.99
|
| Rate for Payer: Ohio Health Group HMO |
$1,333.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.30
|
| Rate for Payer: PHCS Commercial |
$1,707.26
|
| Rate for Payer: United Healthcare All Payer |
$1,564.99
|
|
|
OMNIFIT CEMENT SPACERS 14MM
|
Facility
|
IP
|
$1,778.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$1,707.26 |
| Rate for Payer: Aetna Commercial |
$1,369.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,387.15
|
| Rate for Payer: Cash Price |
$889.20
|
| Rate for Payer: Cigna Commercial |
$1,476.07
|
| Rate for Payer: First Health Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial |
$1,511.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,458.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,312.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$533.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,564.99
|
| Rate for Payer: Ohio Health Group HMO |
$1,333.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.30
|
| Rate for Payer: PHCS Commercial |
$1,707.26
|
| Rate for Payer: United Healthcare All Payer |
$1,564.99
|
|
|
OMNIFIT CEMENT SPACERS 15MM
|
Facility
|
OP
|
$1,778.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$1,707.26 |
| Rate for Payer: Aetna Commercial |
$1,369.37
|
| Rate for Payer: Anthem Medicaid |
$611.59
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,387.15
|
| Rate for Payer: Cash Price |
$889.20
|
| Rate for Payer: Cigna Commercial |
$1,476.07
|
| Rate for Payer: First Health Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial |
$1,511.64
|
| Rate for Payer: Humana KY Medicaid |
$611.59
|
| Rate for Payer: Kentucky WC Medicaid |
$617.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,458.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,312.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$533.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$623.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,564.99
|
| Rate for Payer: Ohio Health Group HMO |
$1,333.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.30
|
| Rate for Payer: PHCS Commercial |
$1,707.26
|
| Rate for Payer: United Healthcare All Payer |
$1,564.99
|
|
|
OMNIFIT CEMENT SPACERS 15MM
|
Facility
|
IP
|
$1,778.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$231.19 |
| Max. Negotiated Rate |
$1,707.26 |
| Rate for Payer: Aetna Commercial |
$1,369.37
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,387.15
|
| Rate for Payer: Cash Price |
$889.20
|
| Rate for Payer: Cigna Commercial |
$1,476.07
|
| Rate for Payer: First Health Commercial |
$1,689.48
|
| Rate for Payer: Humana Commercial |
$1,511.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,458.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,312.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$533.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,564.99
|
| Rate for Payer: Ohio Health Group HMO |
$1,333.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$355.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$231.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$551.30
|
| Rate for Payer: PHCS Commercial |
$1,707.26
|
| Rate for Payer: United Healthcare All Payer |
$1,564.99
|
|
|
OMNIFIT CEMENT SPACERS 16MM
|
Facility
|
OP
|
$1,527.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.54 |
| Max. Negotiated Rate |
$1,466.11 |
| Rate for Payer: Aetna Commercial |
$1,175.94
|
| Rate for Payer: Anthem Medicaid |
$525.20
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,191.22
|
| Rate for Payer: Cash Price |
$763.60
|
| Rate for Payer: Cigna Commercial |
$1,267.58
|
| Rate for Payer: First Health Commercial |
$1,450.84
|
| Rate for Payer: Humana Commercial |
$1,298.12
|
| Rate for Payer: Humana KY Medicaid |
$525.20
|
| Rate for Payer: Kentucky WC Medicaid |
$530.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,252.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,127.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$458.16
|
| Rate for Payer: Molina Healthcare Medicaid |
$535.74
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,343.94
|
| Rate for Payer: Ohio Health Group HMO |
$1,145.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$473.43
|
| Rate for Payer: PHCS Commercial |
$1,466.11
|
| Rate for Payer: United Healthcare All Payer |
$1,343.94
|
|
|
OMNIFIT CEMENT SPACERS 16MM
|
Facility
|
IP
|
$1,527.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$198.54 |
| Max. Negotiated Rate |
$1,466.11 |
| Rate for Payer: Aetna Commercial |
$1,175.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,191.22
|
| Rate for Payer: Cash Price |
$763.60
|
| Rate for Payer: Cigna Commercial |
$1,267.58
|
| Rate for Payer: First Health Commercial |
$1,450.84
|
| Rate for Payer: Humana Commercial |
$1,298.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,252.30
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,127.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$458.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,343.94
|
| Rate for Payer: Ohio Health Group HMO |
$1,145.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$305.44
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$198.54
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$473.43
|
| Rate for Payer: PHCS Commercial |
$1,466.11
|
| Rate for Payer: United Healthcare All Payer |
$1,343.94
|
|
