|
STAGE ONE CEMENT SPACER MOLD
|
Facility
|
IP
|
$12,997.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,899.39 |
| Max. Negotiated Rate |
$12,478.04 |
| Rate for Payer: Aetna Commercial |
$10,008.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,138.41
|
| Rate for Payer: Cash Price |
$6,498.98
|
| Rate for Payer: Cigna Commercial |
$10,788.31
|
| Rate for Payer: First Health Commercial |
$12,348.06
|
| Rate for Payer: Humana Commercial |
$11,048.27
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,658.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,592.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,899.39
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,438.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,748.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,398.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,308.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,968.59
|
| Rate for Payer: PHCS Commercial |
$12,478.04
|
| Rate for Payer: United Healthcare All Payer |
$11,438.20
|
|
|
STAGE ONE CEMENT SPACER MOLD
|
Facility
|
OP
|
$12,997.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,899.39 |
| Max. Negotiated Rate |
$12,478.04 |
| Rate for Payer: Aetna Commercial |
$10,008.43
|
| Rate for Payer: Anthem Medicaid |
$4,470.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,138.41
|
| Rate for Payer: Cash Price |
$6,498.98
|
| Rate for Payer: Cigna Commercial |
$10,788.31
|
| Rate for Payer: First Health Commercial |
$12,348.06
|
| Rate for Payer: Humana Commercial |
$11,048.27
|
| Rate for Payer: Humana KY Medicaid |
$4,470.00
|
| Rate for Payer: Kentucky WC Medicaid |
$4,515.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,658.33
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,592.49
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,899.39
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,559.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,438.20
|
| Rate for Payer: Ohio Health Group HMO |
$9,748.47
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,398.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,308.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,968.59
|
| Rate for Payer: PHCS Commercial |
$12,478.04
|
| Rate for Payer: United Healthcare All Payer |
$11,438.20
|
|
|
STALEVO - 100 TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781563701
|
| Hospital Charge Code |
25001425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO - 100 TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781563701
|
| Hospital Charge Code |
25001425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO 125 TABLET
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781564101
|
| Hospital Charge Code |
25001427
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO 125 TABLET
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781564101
|
| Hospital Charge Code |
25001427
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO-150 TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781565401
|
| Hospital Charge Code |
25001429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO-150 TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781565401
|
| Hospital Charge Code |
25001429
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO 200 TABLET
|
Facility
|
OP
|
$11.09
|
|
|
Service Code
|
NDC 47335000688
|
| Hospital Charge Code |
25001428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$10.65 |
| Rate for Payer: Aetna Commercial |
$8.54
|
| Rate for Payer: Anthem Medicaid |
$3.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.65
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: First Health Commercial |
$10.54
|
| Rate for Payer: Humana Commercial |
$9.43
|
| Rate for Payer: Humana KY Medicaid |
$3.81
|
| Rate for Payer: Kentucky WC Medicaid |
$3.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.76
|
| Rate for Payer: Ohio Health Group HMO |
$8.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.65
|
| Rate for Payer: PHCS Commercial |
$10.65
|
| Rate for Payer: United Healthcare All Payer |
$9.76
|
|
|
STALEVO 200 TABLET
|
Facility
|
IP
|
$11.09
|
|
|
Service Code
|
NDC 47335000688
|
| Hospital Charge Code |
25001428
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.33 |
| Max. Negotiated Rate |
$10.65 |
| Rate for Payer: Aetna Commercial |
$8.54
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.65
|
| Rate for Payer: Cash Price |
$5.54
|
| Rate for Payer: Cigna Commercial |
$9.20
|
| Rate for Payer: First Health Commercial |
$10.54
|
| Rate for Payer: Humana Commercial |
$9.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.76
|
| Rate for Payer: Ohio Health Group HMO |
$8.32
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.65
|
| Rate for Payer: PHCS Commercial |
$10.65
|
| Rate for Payer: United Healthcare All Payer |
$9.76
|
|
|
STALEVO - 50 TAB
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 781561301
|
| Hospital Charge Code |
25001426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STALEVO - 50 TAB
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 781561301
|
| Hospital Charge Code |
25001426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$10.56 |
| Rate for Payer: Aetna Commercial |
$8.47
|
| Rate for Payer: Anthem Medicaid |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8.58
|
| Rate for Payer: Cash Price |
$5.50
|
| Rate for Payer: Cigna Commercial |
$9.13
|
| Rate for Payer: First Health Commercial |
$10.45
|
| Rate for Payer: Humana Commercial |
$9.35
|
| Rate for Payer: Humana KY Medicaid |
$3.78
|
| Rate for Payer: Kentucky WC Medicaid |
$3.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$9.68
|
| Rate for Payer: Ohio Health Group HMO |
$8.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.59
|
| Rate for Payer: PHCS Commercial |
$10.56
|
| Rate for Payer: United Healthcare All Payer |
$9.68
|
|
|
STANDARD OFFSET NEU MOD NECK
|
Facility
|
IP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
STANDARD OFFSET NEU MOD NECK
|
Facility
|
OP
|
$3,875.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,162.50 |
| Max. Negotiated Rate |
$3,720.00 |
| Rate for Payer: Aetna Commercial |
$2,983.75
|
| Rate for Payer: Anthem Medicaid |
$1,332.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,022.50
|
| Rate for Payer: Cash Price |
$1,937.50
|
| Rate for Payer: Cigna Commercial |
$3,216.25
|
| Rate for Payer: First Health Commercial |
$3,681.25
|
| Rate for Payer: Humana Commercial |
$3,293.75
|
| Rate for Payer: Humana KY Medicaid |
$1,332.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1,346.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,177.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,859.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,162.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,359.35
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,410.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,906.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,100.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,371.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,673.75
|
| Rate for Payer: PHCS Commercial |
$3,720.00
|
| Rate for Payer: United Healthcare All Payer |
$3,410.00
|
|
|
STAPH EPI HSP60 GENE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001299
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$20.05
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$20.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
STAPH EPI HSP60 GENE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001299
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
STAPH LUGDUNENSIS SODA GENE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001304
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
STAPH LUGDUNENSIS SODA GENE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001304
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$20.05
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$20.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
STAPH SP TUF GENE
|
Facility
|
IP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001294
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$21.60 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$21.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
STAPH SP TUF GENE
|
Facility
|
OP
|
$72.00
|
|
|
Service Code
|
HCPCS 87149
|
| Hospital Charge Code |
30001294
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$20.05 |
| Max. Negotiated Rate |
$69.12 |
| Rate for Payer: Aetna Commercial |
$55.44
|
| Rate for Payer: Anthem Medicaid |
$20.05
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$20.05
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$57.82
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$28.07
|
| Rate for Payer: CareSource Just4Me Medicare |
$20.05
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$59.76
|
| Rate for Payer: First Health Commercial |
$68.40
|
| Rate for Payer: Humana Commercial |
$61.20
|
| Rate for Payer: Humana KY Medicaid |
$20.05
|
| Rate for Payer: Humana Medicare Advantage |
$20.05
|
| Rate for Payer: Kentucky WC Medicaid |
$20.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$59.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$53.14
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$24.06
|
| Rate for Payer: Molina Healthcare Medicaid |
$20.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$63.36
|
| Rate for Payer: Ohio Health Group HMO |
$54.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$57.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$62.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$49.68
|
| Rate for Payer: PHCS Commercial |
$69.12
|
| Rate for Payer: United Healthcare All Payer |
$63.36
|
|
|
STAPLE COMPRESSION 8*8MM
|
Facility
|
OP
|
$5,731.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem Medicaid |
$1,970.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Humana KY Medicaid |
$1,970.98
|
| Rate for Payer: Kentucky WC Medicaid |
$1,991.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,010.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
STAPLE COMPRESSION 8*8MM
|
Facility
|
IP
|
$5,731.25
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,719.38 |
| Max. Negotiated Rate |
$5,502.00 |
| Rate for Payer: Aetna Commercial |
$4,413.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,470.38
|
| Rate for Payer: Cash Price |
$2,865.62
|
| Rate for Payer: Cigna Commercial |
$4,756.94
|
| Rate for Payer: First Health Commercial |
$5,444.69
|
| Rate for Payer: Humana Commercial |
$4,871.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,699.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,229.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,719.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,043.50
|
| Rate for Payer: Ohio Health Group HMO |
$4,298.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,585.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,986.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,954.56
|
| Rate for Payer: PHCS Commercial |
$5,502.00
|
| Rate for Payer: United Healthcare All Payer |
$5,043.50
|
|
|
STAPLE MINI REFLEX 10*10MM
|
Facility
|
IP
|
$5,712.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.75 |
| Max. Negotiated Rate |
$5,484.00 |
| Rate for Payer: Aetna Commercial |
$4,398.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,455.75
|
| Rate for Payer: Cash Price |
$2,856.25
|
| Rate for Payer: Cigna Commercial |
$4,741.38
|
| Rate for Payer: First Health Commercial |
$5,426.88
|
| Rate for Payer: Humana Commercial |
$4,855.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,684.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,215.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,713.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,027.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,284.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,570.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,969.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,941.62
|
| Rate for Payer: PHCS Commercial |
$5,484.00
|
| Rate for Payer: United Healthcare All Payer |
$5,027.00
|
|
|
STAPLE MINI REFLEX 10*10MM
|
Facility
|
OP
|
$5,712.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,713.75 |
| Max. Negotiated Rate |
$5,484.00 |
| Rate for Payer: Aetna Commercial |
$4,398.62
|
| Rate for Payer: Anthem Medicaid |
$1,964.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,455.75
|
| Rate for Payer: Cash Price |
$2,856.25
|
| Rate for Payer: Cigna Commercial |
$4,741.38
|
| Rate for Payer: First Health Commercial |
$5,426.88
|
| Rate for Payer: Humana Commercial |
$4,855.62
|
| Rate for Payer: Humana KY Medicaid |
$1,964.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1,984.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,684.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,215.82
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,713.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,003.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$5,027.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,284.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,570.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,969.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,941.62
|
| Rate for Payer: PHCS Commercial |
$5,484.00
|
| Rate for Payer: United Healthcare All Payer |
$5,027.00
|
|
|
STAPLE SYSTEM 12*12*12
|
Facility
|
IP
|
$7,380.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,214.00 |
| Max. Negotiated Rate |
$7,084.80 |
| Rate for Payer: Aetna Commercial |
$5,682.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,756.40
|
| Rate for Payer: Cash Price |
$3,690.00
|
| Rate for Payer: Cigna Commercial |
$6,125.40
|
| Rate for Payer: First Health Commercial |
$7,011.00
|
| Rate for Payer: Humana Commercial |
$6,273.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,051.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,446.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,214.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,494.40
|
| Rate for Payer: Ohio Health Group HMO |
$5,535.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,904.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,420.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,092.20
|
| Rate for Payer: PHCS Commercial |
$7,084.80
|
| Rate for Payer: United Healthcare All Payer |
$6,494.40
|
|
