|
REF NO HOLE SHELL 62MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF NO HOLE SHELL 64MM
|
Facility
|
OP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem Medicaid |
$2,218.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Humana KY Medicaid |
$2,218.16
|
| Rate for Payer: Kentucky WC Medicaid |
$2,240.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,262.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF NO HOLE SHELL 64MM
|
Facility
|
IP
|
$6,450.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$838.50 |
| Max. Negotiated Rate |
$6,192.00 |
| Rate for Payer: Aetna Commercial |
$4,966.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,031.00
|
| Rate for Payer: Cash Price |
$3,225.00
|
| Rate for Payer: Cigna Commercial |
$5,353.50
|
| Rate for Payer: First Health Commercial |
$6,127.50
|
| Rate for Payer: Humana Commercial |
$5,482.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,289.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,760.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,935.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,676.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,837.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,290.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$838.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,999.50
|
| Rate for Payer: PHCS Commercial |
$6,192.00
|
| Rate for Payer: United Healthcare All Payer |
$5,676.00
|
|
|
REF RC3 SZ 46MM
|
Facility
|
IP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 46MM
|
Facility
|
OP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem Medicaid |
$4,243.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Humana KY Medicaid |
$4,243.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,328.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 54MM
|
Facility
|
OP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem Medicaid |
$4,243.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Humana KY Medicaid |
$4,243.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,328.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 54MM
|
Facility
|
IP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 56MM
|
Facility
|
IP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 56MM
|
Facility
|
OP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem Medicaid |
$4,243.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Humana KY Medicaid |
$4,243.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,328.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 60MM
|
Facility
|
OP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem Medicaid |
$4,243.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Humana KY Medicaid |
$4,243.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,328.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 60MM
|
Facility
|
IP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 62MM
|
Facility
|
OP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem Medicaid |
$4,243.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Humana KY Medicaid |
$4,243.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,328.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 62MM
|
Facility
|
IP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 64MM
|
Facility
|
OP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem Medicaid |
$4,243.46
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Humana KY Medicaid |
$4,243.46
|
| Rate for Payer: Kentucky WC Medicaid |
$4,286.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,328.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REF RC3 SZ 64MM
|
Facility
|
IP
|
$12,339.23
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,604.10 |
| Max. Negotiated Rate |
$11,845.66 |
| Rate for Payer: Aetna Commercial |
$9,501.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,624.60
|
| Rate for Payer: Cash Price |
$6,169.61
|
| Rate for Payer: Cigna Commercial |
$10,241.56
|
| Rate for Payer: First Health Commercial |
$11,722.27
|
| Rate for Payer: Humana Commercial |
$10,488.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,118.17
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,106.35
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,701.77
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,858.52
|
| Rate for Payer: Ohio Health Group HMO |
$9,254.42
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,467.85
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,604.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,825.16
|
| Rate for Payer: PHCS Commercial |
$11,845.66
|
| Rate for Payer: United Healthcare All Payer |
$10,858.52
|
|
|
REFRESH EA DOSE(ARTTEAR 30 EA)
|
Facility
|
IP
|
$4.51
|
|
|
Service Code
|
NDC 23050601
|
| Hospital Charge Code |
25001293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
REFRESH EA DOSE(ARTTEAR 30 EA)
|
Facility
|
OP
|
$4.51
|
|
|
Service Code
|
NDC 23050601
|
| Hospital Charge Code |
25001293
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$4.33 |
| Rate for Payer: Aetna Commercial |
$3.47
|
| Rate for Payer: Anthem Medicaid |
$1.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.52
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cigna Commercial |
$3.74
|
| Rate for Payer: First Health Commercial |
$4.28
|
| Rate for Payer: Humana Commercial |
$3.83
|
| Rate for Payer: Humana KY Medicaid |
$1.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.33
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.35
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.97
|
| Rate for Payer: Ohio Health Group HMO |
$3.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.40
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
REFRESH TEARS DROPS (15ML)
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
25003400
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
REFRESH TEARS DROPS (15ML)
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
25003400
|
|
Hospital Revenue Code
|
637
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna Commercial |
$0.02
|
| Rate for Payer: Anthem Medicaid |
$0.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna Commercial |
$0.02
|
| Rate for Payer: First Health Commercial |
$0.03
|
| Rate for Payer: Humana Commercial |
$0.03
|
| Rate for Payer: Humana KY Medicaid |
$0.01
|
| Rate for Payer: Kentucky WC Medicaid |
$0.01
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.02
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.03
|
| Rate for Payer: Ohio Health Group HMO |
$0.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.01
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
REF SP3 3H SHELL 40MM
|
Facility
|
IP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
REF SP3 3H SHELL 40MM
|
Facility
|
OP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem Medicaid |
$3,960.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Humana KY Medicaid |
$3,960.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,000.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,039.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
REF SP3 3H SHELL 42MM
|
Facility
|
OP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem Medicaid |
$3,960.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Humana KY Medicaid |
$3,960.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,000.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,039.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
REF SP3 3H SHELL 42MM
|
Facility
|
IP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
REF SP3 3H SHELL 44MM
|
Facility
|
OP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem Medicaid |
$3,960.15
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Humana KY Medicaid |
$3,960.15
|
| Rate for Payer: Kentucky WC Medicaid |
$4,000.46
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,039.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
|
REF SP3 3H SHELL 44MM
|
Facility
|
IP
|
$11,515.42
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,497.00 |
| Max. Negotiated Rate |
$11,054.80 |
| Rate for Payer: Aetna Commercial |
$8,866.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,982.03
|
| Rate for Payer: Cash Price |
$5,757.71
|
| Rate for Payer: Cigna Commercial |
$9,557.80
|
| Rate for Payer: First Health Commercial |
$10,939.65
|
| Rate for Payer: Humana Commercial |
$9,788.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,442.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,498.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,454.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,133.57
|
| Rate for Payer: Ohio Health Group HMO |
$8,636.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,303.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,497.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,569.78
|
| Rate for Payer: PHCS Commercial |
$11,054.80
|
| Rate for Payer: United Healthcare All Payer |
$10,133.57
|
|
