|
SIZER STYLE MOD+ 525CC
|
Facility
|
IP
|
$1,100.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$330.00 |
| Max. Negotiated Rate |
$1,056.00 |
| Rate for Payer: Aetna Commercial |
$847.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$858.00
|
| Rate for Payer: Cash Price |
$550.00
|
| Rate for Payer: Cigna Commercial |
$913.00
|
| Rate for Payer: First Health Commercial |
$1,045.00
|
| Rate for Payer: Humana Commercial |
$935.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$902.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$811.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$330.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$968.00
|
| Rate for Payer: Ohio Health Group HMO |
$825.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$880.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$957.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$759.00
|
| Rate for Payer: PHCS Commercial |
$1,056.00
|
| Rate for Payer: United Healthcare All Payer |
$968.00
|
|
|
SIZER STYLE MOD RE-STERL 375CC
|
Facility
|
IP
|
$2,975.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Aetna Commercial |
$2,290.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.50
|
| Rate for Payer: Cash Price |
$1,487.50
|
| Rate for Payer: Cigna Commercial |
$2,469.25
|
| Rate for Payer: First Health Commercial |
$2,826.25
|
| Rate for Payer: Humana Commercial |
$2,528.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,618.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.75
|
| Rate for Payer: PHCS Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Payer |
$2,618.00
|
|
|
SIZER STYLE MOD RE-STERL 375CC
|
Facility
|
OP
|
$2,975.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Aetna Commercial |
$2,290.75
|
| Rate for Payer: Anthem Medicaid |
$1,023.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.50
|
| Rate for Payer: Cash Price |
$1,487.50
|
| Rate for Payer: Cigna Commercial |
$2,469.25
|
| Rate for Payer: First Health Commercial |
$2,826.25
|
| Rate for Payer: Humana Commercial |
$2,528.75
|
| Rate for Payer: Humana KY Medicaid |
$1,023.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,033.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,043.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,618.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.75
|
| Rate for Payer: PHCS Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Payer |
$2,618.00
|
|
|
SIZER STYLE MOD RE-STRIL 600CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE MOD RE-STRIL 600CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE MOD RE-STRIL 640CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE MOD RE-STRIL 640CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE XFUL RE-STERIL 310
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE XFUL RE-STERIL 310
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE XFUL RE-STRIL 580C
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYLE XFUL RE-STRIL 580C
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYL FULL RE-STERL 650CC
|
Facility
|
IP
|
$2,975.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Aetna Commercial |
$2,290.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.50
|
| Rate for Payer: Cash Price |
$1,487.50
|
| Rate for Payer: Cigna Commercial |
$2,469.25
|
| Rate for Payer: First Health Commercial |
$2,826.25
|
| Rate for Payer: Humana Commercial |
$2,528.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,618.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.75
|
| Rate for Payer: PHCS Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Payer |
$2,618.00
|
|
|
SIZER STYL FULL RE-STERL 650CC
|
Facility
|
OP
|
$2,975.00
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$892.50 |
| Max. Negotiated Rate |
$2,856.00 |
| Rate for Payer: Aetna Commercial |
$2,290.75
|
| Rate for Payer: Anthem Medicaid |
$1,023.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,320.50
|
| Rate for Payer: Cash Price |
$1,487.50
|
| Rate for Payer: Cigna Commercial |
$2,469.25
|
| Rate for Payer: First Health Commercial |
$2,826.25
|
| Rate for Payer: Humana Commercial |
$2,528.75
|
| Rate for Payer: Humana KY Medicaid |
$1,023.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,033.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,439.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,195.55
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$892.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,043.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,618.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,231.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,380.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,588.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,052.75
|
| Rate for Payer: PHCS Commercial |
$2,856.00
|
| Rate for Payer: United Healthcare All Payer |
$2,618.00
|
|
|
SIZER STYL FULL RE-STERL 770CC
|
Facility
|
OP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem Medicaid |
$1,010.21
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Humana KY Medicaid |
$1,010.21
|
| Rate for Payer: Kentucky WC Medicaid |
$1,020.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,030.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SIZER STYL FULL RE-STERL 770CC
|
Facility
|
IP
|
$2,937.50
|
|
|
Service Code
|
HCPCS C1789
|
| Hospital Charge Code |
27000109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$881.25 |
| Max. Negotiated Rate |
$2,820.00 |
| Rate for Payer: Aetna Commercial |
$2,261.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,291.25
|
| Rate for Payer: Cash Price |
$1,468.75
|
| Rate for Payer: Cigna Commercial |
$2,438.12
|
| Rate for Payer: First Health Commercial |
$2,790.62
|
| Rate for Payer: Humana Commercial |
$2,496.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,408.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,167.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$881.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,585.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,203.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,350.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,555.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,026.88
|
| Rate for Payer: PHCS Commercial |
$2,820.00
|
| Rate for Payer: United Healthcare All Payer |
$2,585.00
|
|
|
SKELAXIN (METAXALONE) 800 MG T
|
Facility
|
OP
|
$10.04
|
|
|
Service Code
|
NDC 68001048500
|
| Hospital Charge Code |
25001409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem Medicaid |
$3.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Humana KY Medicaid |
$3.45
|
| Rate for Payer: Kentucky WC Medicaid |
$3.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
SKELAXIN (METAXALONE) 800 MG T
|
Facility
|
IP
|
$10.04
|
|
|
Service Code
|
NDC 68001048500
|
| Hospital Charge Code |
25001409
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.01 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna Commercial |
$7.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.83
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna Commercial |
$8.33
|
| Rate for Payer: First Health Commercial |
$9.54
|
| Rate for Payer: Humana Commercial |
$8.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.23
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.84
|
| Rate for Payer: Ohio Health Group HMO |
$7.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.03
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.93
|
| Rate for Payer: PHCS Commercial |
$9.64
|
| Rate for Payer: United Healthcare All Payer |
$8.84
|
|
|
SKELETAL FIX TIBIAL SHAFT FX
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 27756
|
| Hospital Charge Code |
76100925
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$413.30 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$827.02
|
| Rate for Payer: Ambetter Exchange |
$562.32
|
| Rate for Payer: Anthem Medicaid |
$413.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$562.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$562.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$674.78
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$906.87
|
| Rate for Payer: Healthspan PPO |
$749.10
|
| Rate for Payer: Humana Medicaid |
$413.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$706.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$562.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$421.57
|
| Rate for Payer: Molina Healthcare Passport |
$413.30
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$731.02
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$417.43
|
| Rate for Payer: Wellcare Medicare Advantage |
$562.32
|
|
|
SKELETAL FIX TIBIAL SHAFT FX
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 27756
|
| Hospital Charge Code |
76100925
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$550.24 |
| Max. Negotiated Rate |
$9,240.92 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem Medicaid |
$550.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$6,600.66
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$9,240.92
|
| Rate for Payer: CareSource Just4Me Medicare |
$8,910.89
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Humana KY Medicaid |
$550.24
|
| Rate for Payer: Humana Medicare Advantage |
$6,600.66
|
| Rate for Payer: Kentucky WC Medicaid |
$555.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,920.79
|
| Rate for Payer: Molina Healthcare Medicaid |
$561.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
SKELETAL FIX TIBIAL SHAFT FX
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
HCPCS 27756
|
| Hospital Charge Code |
76100925
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$480.00 |
| Max. Negotiated Rate |
$1,536.00 |
| Rate for Payer: Aetna Commercial |
$1,232.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,248.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$1,328.00
|
| Rate for Payer: First Health Commercial |
$1,520.00
|
| Rate for Payer: Humana Commercial |
$1,360.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,312.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,180.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$480.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,408.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,200.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,280.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,392.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,104.00
|
| Rate for Payer: PHCS Commercial |
$1,536.00
|
| Rate for Payer: United Healthcare All Payer |
$1,408.00
|
|
|
SKELETAL FIX TIBIAL SHAFT FX(P
|
Professional
|
Both
|
$1,600.00
|
|
|
Service Code
|
HCPCS 27756
|
| Hospital Charge Code |
761P0925
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$413.30 |
| Max. Negotiated Rate |
$960.00 |
| Rate for Payer: Aetna Commercial |
$827.02
|
| Rate for Payer: Ambetter Exchange |
$562.32
|
| Rate for Payer: Anthem Medicaid |
$413.30
|
| Rate for Payer: Buckeye Individual/Medicaid |
$562.32
|
| Rate for Payer: Buckeye Medicare Advantage |
$562.32
|
| Rate for Payer: CareSource Just4Me Medicare |
$674.78
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cash Price |
$800.00
|
| Rate for Payer: Cigna Commercial |
$906.87
|
| Rate for Payer: Healthspan PPO |
$749.10
|
| Rate for Payer: Humana Medicaid |
$413.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$706.97
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$562.32
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$562.32
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$421.57
|
| Rate for Payer: Molina Healthcare Passport |
$413.30
|
| Rate for Payer: Multiplan PHCS |
$960.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$731.02
|
| Rate for Payer: UHCCP Medicaid |
$560.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$417.43
|
| Rate for Payer: Wellcare Medicare Advantage |
$562.32
|
|
|
SKEL FIX DSTL PHLN FX FNG/THB
|
Facility
|
OP
|
$610.00
|
|
|
Service Code
|
HCPCS 26756
|
| Hospital Charge Code |
76100745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$209.78 |
| Max. Negotiated Rate |
$4,197.13 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem Medicaid |
$209.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$2,997.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$4,197.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$4,047.23
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Humana KY Medicaid |
$209.78
|
| Rate for Payer: Humana Medicare Advantage |
$2,997.95
|
| Rate for Payer: Kentucky WC Medicaid |
$211.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,597.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$213.99
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$530.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.90
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
SKEL FIX DSTL PHLN FX FNG/THB
|
Facility
|
IP
|
$610.00
|
|
|
Service Code
|
HCPCS 26756
|
| Hospital Charge Code |
76100745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$183.00 |
| Max. Negotiated Rate |
$585.60 |
| Rate for Payer: Aetna Commercial |
$469.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$475.80
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$506.30
|
| Rate for Payer: First Health Commercial |
$579.50
|
| Rate for Payer: Humana Commercial |
$518.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$500.20
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$450.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$183.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$536.80
|
| Rate for Payer: Ohio Health Group HMO |
$457.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$488.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$530.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$420.90
|
| Rate for Payer: PHCS Commercial |
$585.60
|
| Rate for Payer: United Healthcare All Payer |
$536.80
|
|
|
SKEL FIX DSTL PHLN FX FNG/THB
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 26756
|
| Hospital Charge Code |
76100745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.93 |
| Max. Negotiated Rate |
$656.57 |
| Rate for Payer: Aetna Commercial |
$580.42
|
| Rate for Payer: Ambetter Exchange |
$405.26
|
| Rate for Payer: Anthem Medicaid |
$181.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$405.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$486.31
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$656.57
|
| Rate for Payer: Healthspan PPO |
$525.74
|
| Rate for Payer: Humana Medicaid |
$181.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$504.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$405.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$185.57
|
| Rate for Payer: Molina Healthcare Passport |
$181.93
|
| Rate for Payer: Multiplan PHCS |
$366.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$526.84
|
| Rate for Payer: UHCCP Medicaid |
$213.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$183.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$405.26
|
|
|
SKEL FIX DSTL PHLN FX FNG/TH(P
|
Professional
|
Both
|
$610.00
|
|
|
Service Code
|
HCPCS 26756
|
| Hospital Charge Code |
761P0745
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$181.93 |
| Max. Negotiated Rate |
$656.57 |
| Rate for Payer: Aetna Commercial |
$580.42
|
| Rate for Payer: Ambetter Exchange |
$405.26
|
| Rate for Payer: Anthem Medicaid |
$181.93
|
| Rate for Payer: Buckeye Individual/Medicaid |
$405.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$405.26
|
| Rate for Payer: CareSource Just4Me Medicare |
$486.31
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cash Price |
$305.00
|
| Rate for Payer: Cigna Commercial |
$656.57
|
| Rate for Payer: Healthspan PPO |
$525.74
|
| Rate for Payer: Humana Medicaid |
$181.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$504.36
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$405.26
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$405.26
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$185.57
|
| Rate for Payer: Molina Healthcare Passport |
$181.93
|
| Rate for Payer: Multiplan PHCS |
$366.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$526.84
|
| Rate for Payer: UHCCP Medicaid |
$213.50
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$183.75
|
| Rate for Payer: Wellcare Medicare Advantage |
$405.26
|
|
