|
REF NO HOLE SHELL 60MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 62MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 62MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 64MM
|
Facility
|
OP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem Medicaid |
$2,286.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Humana KY Medicaid |
$2,286.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,310.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,332.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF NO HOLE SHELL 64MM
|
Facility
|
IP
|
$6,650.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,995.00 |
| Max. Negotiated Rate |
$6,384.00 |
| Rate for Payer: Aetna Commercial |
$5,120.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,187.00
|
| Rate for Payer: Cash Price |
$3,325.00
|
| Rate for Payer: Cigna Commercial |
$5,519.50
|
| Rate for Payer: First Health Commercial |
$6,317.50
|
| Rate for Payer: Humana Commercial |
$5,652.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,453.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,907.70
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,995.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,852.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,987.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,320.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,785.50
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,588.50
|
| Rate for Payer: PHCS Commercial |
$6,384.00
|
| Rate for Payer: United Healthcare All Payer |
$5,852.00
|
|
|
REF RC3 SZ 46MM
|
Facility
|
OP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem Medicaid |
$4,329.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Humana KY Medicaid |
$4,329.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,373.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,416.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 46MM
|
Facility
|
IP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 54MM
|
Facility
|
IP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 54MM
|
Facility
|
OP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem Medicaid |
$4,329.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Humana KY Medicaid |
$4,329.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,373.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,416.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 56MM
|
Facility
|
IP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 56MM
|
Facility
|
OP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem Medicaid |
$4,329.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Humana KY Medicaid |
$4,329.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,373.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,416.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 60MM
|
Facility
|
IP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 60MM
|
Facility
|
OP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem Medicaid |
$4,329.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Humana KY Medicaid |
$4,329.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,373.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,416.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 62MM
|
Facility
|
IP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 62MM
|
Facility
|
OP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem Medicaid |
$4,329.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Humana KY Medicaid |
$4,329.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,373.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,416.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 64MM
|
Facility
|
OP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem Medicaid |
$4,329.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Humana KY Medicaid |
$4,329.27
|
| Rate for Payer: Kentucky WC Medicaid |
$4,373.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,416.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
REF RC3 SZ 64MM
|
Facility
|
IP
|
$12,588.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,776.62 |
| Max. Negotiated Rate |
$12,085.20 |
| Rate for Payer: Aetna Commercial |
$9,693.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,819.23
|
| Rate for Payer: Cash Price |
$6,294.38
|
| Rate for Payer: Cigna Commercial |
$10,448.66
|
| Rate for Payer: First Health Commercial |
$11,959.31
|
| Rate for Payer: Humana Commercial |
$10,700.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,322.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,290.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,776.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,078.10
|
| Rate for Payer: Ohio Health Group HMO |
$9,441.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,071.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,952.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,686.24
|
| Rate for Payer: PHCS Commercial |
$12,085.20
|
| Rate for Payer: United Healthcare All Payer |
$11,078.10
|
|
|
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 |
$1.35 |
| 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 |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
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 |
$1.35 |
| 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 |
$3.61
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.11
|
| Rate for Payer: PHCS Commercial |
$4.33
|
| Rate for Payer: United Healthcare All Payer |
$3.97
|
|
|
REFRESH TEARS DROPS (15ML)
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
25003400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
REFRESH TEARS DROPS (15ML)
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS A9270
|
| Hospital Charge Code |
25003400
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.01 |
| 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 |
$0.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.03
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Payer |
$0.03
|
|
|
REF SP3 3H SHELL 40MM
|
Facility
|
IP
|
$11,760.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,528.13 |
| Max. Negotiated Rate |
$11,290.02 |
| Rate for Payer: Aetna Commercial |
$9,055.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,173.14
|
| Rate for Payer: Cash Price |
$5,880.22
|
| Rate for Payer: Cigna Commercial |
$9,761.17
|
| Rate for Payer: First Health Commercial |
$11,172.42
|
| Rate for Payer: Humana Commercial |
$9,996.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,643.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,679.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,528.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,349.19
|
| Rate for Payer: Ohio Health Group HMO |
$8,820.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,231.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,114.70
|
| Rate for Payer: PHCS Commercial |
$11,290.02
|
| Rate for Payer: United Healthcare All Payer |
$10,349.19
|
|
|
REF SP3 3H SHELL 40MM
|
Facility
|
OP
|
$11,760.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,528.13 |
| Max. Negotiated Rate |
$11,290.02 |
| Rate for Payer: Aetna Commercial |
$9,055.54
|
| Rate for Payer: Anthem Medicaid |
$4,044.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,173.14
|
| Rate for Payer: Cash Price |
$5,880.22
|
| Rate for Payer: Cigna Commercial |
$9,761.17
|
| Rate for Payer: First Health Commercial |
$11,172.42
|
| Rate for Payer: Humana Commercial |
$9,996.37
|
| Rate for Payer: Humana KY Medicaid |
$4,044.42
|
| Rate for Payer: Kentucky WC Medicaid |
$4,085.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,643.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,679.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,528.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,125.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,349.19
|
| Rate for Payer: Ohio Health Group HMO |
$8,820.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,231.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,114.70
|
| Rate for Payer: PHCS Commercial |
$11,290.02
|
| Rate for Payer: United Healthcare All Payer |
$10,349.19
|
|
|
REF SP3 3H SHELL 42MM
|
Facility
|
OP
|
$11,760.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,528.13 |
| Max. Negotiated Rate |
$11,290.02 |
| Rate for Payer: Aetna Commercial |
$9,055.54
|
| Rate for Payer: Anthem Medicaid |
$4,044.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,173.14
|
| Rate for Payer: Cash Price |
$5,880.22
|
| Rate for Payer: Cigna Commercial |
$9,761.17
|
| Rate for Payer: First Health Commercial |
$11,172.42
|
| Rate for Payer: Humana Commercial |
$9,996.37
|
| Rate for Payer: Humana KY Medicaid |
$4,044.42
|
| Rate for Payer: Kentucky WC Medicaid |
$4,085.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,643.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,679.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,528.13
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,125.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,349.19
|
| Rate for Payer: Ohio Health Group HMO |
$8,820.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,231.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,114.70
|
| Rate for Payer: PHCS Commercial |
$11,290.02
|
| Rate for Payer: United Healthcare All Payer |
$10,349.19
|
|
|
REF SP3 3H SHELL 42MM
|
Facility
|
IP
|
$11,760.44
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,528.13 |
| Max. Negotiated Rate |
$11,290.02 |
| Rate for Payer: Aetna Commercial |
$9,055.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,173.14
|
| Rate for Payer: Cash Price |
$5,880.22
|
| Rate for Payer: Cigna Commercial |
$9,761.17
|
| Rate for Payer: First Health Commercial |
$11,172.42
|
| Rate for Payer: Humana Commercial |
$9,996.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,643.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,679.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,528.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,349.19
|
| Rate for Payer: Ohio Health Group HMO |
$8,820.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$9,408.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,231.58
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,114.70
|
| Rate for Payer: PHCS Commercial |
$11,290.02
|
| Rate for Payer: United Healthcare All Payer |
$10,349.19
|
|
