|
SWANSON PIP IMP SZ6 W/GROMMETS
|
Facility
|
OP
|
$7,691.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$999.83 |
| Max. Negotiated Rate |
$7,383.36 |
| Rate for Payer: Aetna Commercial |
$5,922.07
|
| Rate for Payer: Anthem Medicaid |
$2,644.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,998.98
|
| Rate for Payer: Cash Price |
$3,845.50
|
| Rate for Payer: Cigna Commercial |
$6,383.53
|
| Rate for Payer: First Health Commercial |
$7,306.45
|
| Rate for Payer: Humana Commercial |
$6,537.35
|
| Rate for Payer: Humana KY Medicaid |
$2,644.93
|
| Rate for Payer: Kentucky WC Medicaid |
$2,671.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,306.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,675.96
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,307.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,698.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,768.08
|
| Rate for Payer: Ohio Health Group HMO |
$5,768.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,538.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$999.83
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,384.21
|
| Rate for Payer: PHCS Commercial |
$7,383.36
|
| Rate for Payer: United Healthcare All Payer |
$6,768.08
|
|
|
SWANSON PIP IMP SZ 7 W/GROMMET
|
Facility
|
IP
|
$4,800.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$624.06 |
| Max. Negotiated Rate |
$4,608.48 |
| Rate for Payer: Aetna Commercial |
$3,696.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,744.39
|
| Rate for Payer: Cash Price |
$2,400.25
|
| Rate for Payer: Cigna Commercial |
$3,984.42
|
| Rate for Payer: First Health Commercial |
$4,560.48
|
| Rate for Payer: Humana Commercial |
$4,080.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,936.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,542.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,440.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,224.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,600.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$624.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,488.16
|
| Rate for Payer: PHCS Commercial |
$4,608.48
|
| Rate for Payer: United Healthcare All Payer |
$4,224.44
|
|
|
SWANSON PIP IMP SZ 7 W/GROMMET
|
Facility
|
OP
|
$4,800.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$624.06 |
| Max. Negotiated Rate |
$4,608.48 |
| Rate for Payer: Aetna Commercial |
$3,696.38
|
| Rate for Payer: Anthem Medicaid |
$1,650.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,744.39
|
| Rate for Payer: Cash Price |
$2,400.25
|
| Rate for Payer: Cigna Commercial |
$3,984.42
|
| Rate for Payer: First Health Commercial |
$4,560.48
|
| Rate for Payer: Humana Commercial |
$4,080.42
|
| Rate for Payer: Humana KY Medicaid |
$1,650.89
|
| Rate for Payer: Kentucky WC Medicaid |
$1,667.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,936.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,542.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,440.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,684.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,224.44
|
| Rate for Payer: Ohio Health Group HMO |
$3,600.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$624.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,488.16
|
| Rate for Payer: PHCS Commercial |
$4,608.48
|
| Rate for Payer: United Healthcare All Payer |
$4,224.44
|
|
|
SWEEN CREAM (85GM)
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 11701000216
|
| Hospital Charge Code |
25003505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
SWEEN CREAM (85GM)
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 11701000216
|
| Hospital Charge Code |
25003505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna Commercial |
$0.04
|
| Rate for Payer: Anthem Medicaid |
$0.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna Commercial |
$0.04
|
| Rate for Payer: First Health Commercial |
$0.05
|
| Rate for Payer: Humana Commercial |
$0.04
|
| Rate for Payer: Humana KY Medicaid |
$0.02
|
| Rate for Payer: Kentucky WC Medicaid |
$0.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$0.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$0.04
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$0.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$0.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$0.04
|
| Rate for Payer: Ohio Health Group HMO |
$0.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$0.02
|
| Rate for Payer: PHCS Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Payer |
$0.04
|
|
|
SWIVELOCK 3.9 ACHILLES
|
Facility
|
OP
|
$13,501.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,755.23 |
| Max. Negotiated Rate |
$12,961.68 |
| Rate for Payer: Aetna Commercial |
$10,396.35
|
| Rate for Payer: Anthem Medicaid |
$4,643.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,531.36
|
| Rate for Payer: Cash Price |
$6,750.88
|
| Rate for Payer: Cigna Commercial |
$11,206.45
|
| Rate for Payer: First Health Commercial |
$12,826.66
|
| Rate for Payer: Humana Commercial |
$11,476.49
|
| Rate for Payer: Humana KY Medicaid |
$4,643.25
|
| Rate for Payer: Kentucky WC Medicaid |
$4,690.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,071.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,964.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,050.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,736.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,881.54
|
| Rate for Payer: Ohio Health Group HMO |
$10,126.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,700.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,755.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,185.54
|
| Rate for Payer: PHCS Commercial |
$12,961.68
|
| Rate for Payer: United Healthcare All Payer |
$11,881.54
|
|
|
SWIVELOCK 3.9 ACHILLES
|
Facility
|
IP
|
$13,501.75
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,755.23 |
| Max. Negotiated Rate |
$12,961.68 |
| Rate for Payer: Aetna Commercial |
$10,396.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,531.36
|
| Rate for Payer: Cash Price |
$6,750.88
|
| Rate for Payer: Cigna Commercial |
$11,206.45
|
| Rate for Payer: First Health Commercial |
$12,826.66
|
| Rate for Payer: Humana Commercial |
$11,476.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,071.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,964.29
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,050.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,881.54
|
| Rate for Payer: Ohio Health Group HMO |
$10,126.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,700.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,755.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,185.54
|
| Rate for Payer: PHCS Commercial |
$12,961.68
|
| Rate for Payer: United Healthcare All Payer |
$11,881.54
|
|
|
SWIVELOCK 4.75*19.1MM PEEK
|
Facility
|
OP
|
$3,512.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem Medicaid |
$1,207.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Humana KY Medicaid |
$1,207.95
|
| Rate for Payer: Kentucky WC Medicaid |
$1,220.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,232.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
SWIVELOCK 4.75*19.1MM PEEK
|
Facility
|
IP
|
$3,512.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$456.62 |
| Max. Negotiated Rate |
$3,372.00 |
| Rate for Payer: Aetna Commercial |
$2,704.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,739.75
|
| Rate for Payer: Cash Price |
$1,756.25
|
| Rate for Payer: Cigna Commercial |
$2,915.38
|
| Rate for Payer: First Health Commercial |
$3,336.88
|
| Rate for Payer: Humana Commercial |
$2,985.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,880.25
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,592.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,053.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,091.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,634.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$702.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$456.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,088.88
|
| Rate for Payer: PHCS Commercial |
$3,372.00
|
| Rate for Payer: United Healthcare All Payer |
$3,091.00
|
|
|
SWIVELOCK 4.75*19.1 W/ BLUE FI
|
Facility
|
IP
|
$3,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$499.85 |
| Max. Negotiated Rate |
$3,691.20 |
| Rate for Payer: Aetna Commercial |
$2,960.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,999.10
|
| Rate for Payer: Cash Price |
$1,922.50
|
| Rate for Payer: Cigna Commercial |
$3,191.35
|
| Rate for Payer: First Health Commercial |
$3,652.75
|
| Rate for Payer: Humana Commercial |
$3,268.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,152.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,837.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,153.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,383.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,883.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,191.95
|
| Rate for Payer: PHCS Commercial |
$3,691.20
|
| Rate for Payer: United Healthcare All Payer |
$3,383.60
|
|
|
SWIVELOCK 4.75*19.1 W/ BLUE FI
|
Facility
|
OP
|
$3,845.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$499.85 |
| Max. Negotiated Rate |
$3,691.20 |
| Rate for Payer: Aetna Commercial |
$2,960.65
|
| Rate for Payer: Anthem Medicaid |
$1,322.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,999.10
|
| Rate for Payer: Cash Price |
$1,922.50
|
| Rate for Payer: Cigna Commercial |
$3,191.35
|
| Rate for Payer: First Health Commercial |
$3,652.75
|
| Rate for Payer: Humana Commercial |
$3,268.25
|
| Rate for Payer: Humana KY Medicaid |
$1,322.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,335.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,152.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,837.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,153.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,348.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,383.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,883.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,191.95
|
| Rate for Payer: PHCS Commercial |
$3,691.20
|
| Rate for Payer: United Healthcare All Payer |
$3,383.60
|
|
|
SWIVELOCK 4.75*19.1 W/CLD EYEL
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
SWIVELOCK 4.75*19.1 W/CLD EYEL
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
SWIVELOCK 4.75*19.1 W/FIBERTAP
|
Facility
|
OP
|
$3,845.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$499.85 |
| Max. Negotiated Rate |
$3,691.20 |
| Rate for Payer: Aetna Commercial |
$2,960.65
|
| Rate for Payer: Anthem Medicaid |
$1,322.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,999.10
|
| Rate for Payer: Cash Price |
$1,922.50
|
| Rate for Payer: Cigna Commercial |
$3,191.35
|
| Rate for Payer: First Health Commercial |
$3,652.75
|
| Rate for Payer: Humana Commercial |
$3,268.25
|
| Rate for Payer: Humana KY Medicaid |
$1,322.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,335.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,152.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,837.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,153.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,348.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,383.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,883.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,191.95
|
| Rate for Payer: PHCS Commercial |
$3,691.20
|
| Rate for Payer: United Healthcare All Payer |
$3,383.60
|
|
|
SWIVELOCK 4.75*19.1 W/FIBERTAP
|
Facility
|
IP
|
$3,845.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$499.85 |
| Max. Negotiated Rate |
$3,691.20 |
| Rate for Payer: Aetna Commercial |
$2,960.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,999.10
|
| Rate for Payer: Cash Price |
$1,922.50
|
| Rate for Payer: Cigna Commercial |
$3,191.35
|
| Rate for Payer: First Health Commercial |
$3,652.75
|
| Rate for Payer: Humana Commercial |
$3,268.25
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,152.90
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,837.61
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,153.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,383.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,883.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$769.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$499.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,191.95
|
| Rate for Payer: PHCS Commercial |
$3,691.20
|
| Rate for Payer: United Healthcare All Payer |
$3,383.60
|
|
|
SWIVELOCK 4.75*24.5 SELF PUNCH
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SWIVELOCK 4.75*24.5 SELF PUNCH
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem Medicaid |
$1,238.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Humana KY Medicaid |
$1,238.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,250.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,262.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SWIVELOCK 5.5*19.1 W/ CLSD EYE
|
Facility
|
OP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem Medicaid |
$1,262.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Humana KY Medicaid |
$1,262.11
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.96
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,287.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
SWIVELOCK 5.5*19.1 W/ CLSD EYE
|
Facility
|
IP
|
$3,670.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$477.10 |
| Max. Negotiated Rate |
$3,523.20 |
| Rate for Payer: Aetna Commercial |
$2,825.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,862.60
|
| Rate for Payer: Cash Price |
$1,835.00
|
| Rate for Payer: Cigna Commercial |
$3,046.10
|
| Rate for Payer: First Health Commercial |
$3,486.50
|
| Rate for Payer: Humana Commercial |
$3,119.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,009.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,708.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,101.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,229.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,752.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$734.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$477.10
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,137.70
|
| Rate for Payer: PHCS Commercial |
$3,523.20
|
| Rate for Payer: United Healthcare All Payer |
$3,229.60
|
|
|
SWIVELOCK 5.5*24.5 SELF PUNCH
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem Medicaid |
$1,238.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Humana KY Medicaid |
$1,238.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,250.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,262.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SWIVELOCK 5.5*24.5 SELF PUNCH
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$468.00 |
| Max. Negotiated Rate |
$3,456.00 |
| Rate for Payer: Aetna Commercial |
$2,772.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,808.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna Commercial |
$2,988.00
|
| Rate for Payer: First Health Commercial |
$3,420.00
|
| Rate for Payer: Humana Commercial |
$3,060.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,952.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,656.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,080.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,168.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,700.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$720.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$468.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,116.00
|
| Rate for Payer: PHCS Commercial |
$3,456.00
|
| Rate for Payer: United Healthcare All Payer |
$3,168.00
|
|
|
SWIVELOCK KNOTLESS
|
Facility
|
OP
|
$3,890.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.76 |
| Max. Negotiated Rate |
$3,734.88 |
| Rate for Payer: Aetna Commercial |
$2,995.68
|
| Rate for Payer: Anthem Medicaid |
$1,337.94
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.59
|
| Rate for Payer: Cash Price |
$1,945.25
|
| Rate for Payer: Cigna Commercial |
$3,229.12
|
| Rate for Payer: First Health Commercial |
$3,695.98
|
| Rate for Payer: Humana Commercial |
$3,306.92
|
| Rate for Payer: Humana KY Medicaid |
$1,337.94
|
| Rate for Payer: Kentucky WC Medicaid |
$1,351.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,190.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,871.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,364.79
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$778.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$505.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,206.06
|
| Rate for Payer: PHCS Commercial |
$3,734.88
|
| Rate for Payer: United Healthcare All Payer |
$3,423.64
|
|
|
SWIVELOCK KNOTLESS
|
Facility
|
IP
|
$3,890.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$505.76 |
| Max. Negotiated Rate |
$3,734.88 |
| Rate for Payer: Aetna Commercial |
$2,995.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,034.59
|
| Rate for Payer: Cash Price |
$1,945.25
|
| Rate for Payer: Cigna Commercial |
$3,229.12
|
| Rate for Payer: First Health Commercial |
$3,695.98
|
| Rate for Payer: Humana Commercial |
$3,306.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,190.21
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,871.19
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,167.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,423.64
|
| Rate for Payer: Ohio Health Group HMO |
$2,917.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$778.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$505.76
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,206.06
|
| Rate for Payer: PHCS Commercial |
$3,734.88
|
| Rate for Payer: United Healthcare All Payer |
$3,423.64
|
|
|
SYMBICORT 160 4.5MCGINH 10.2GM
|
Facility
|
OP
|
$9.62
|
|
|
Service Code
|
NDC 186037028
|
| Hospital Charge Code |
25003506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.41
|
| Rate for Payer: Anthem Medicaid |
$3.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.50
|
| Rate for Payer: Cash Price |
$4.81
|
| Rate for Payer: Cigna Commercial |
$7.98
|
| Rate for Payer: First Health Commercial |
$9.14
|
| Rate for Payer: Humana Commercial |
$8.18
|
| Rate for Payer: Humana KY Medicaid |
$3.31
|
| Rate for Payer: Kentucky WC Medicaid |
$3.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
|
SYMBICORT 160 4.5MCGINH 10.2GM
|
Facility
|
IP
|
$9.62
|
|
|
Service Code
|
NDC 186037028
|
| Hospital Charge Code |
25003506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$9.24 |
| Rate for Payer: Aetna Commercial |
$7.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.50
|
| Rate for Payer: Cash Price |
$4.81
|
| Rate for Payer: Cigna Commercial |
$7.98
|
| Rate for Payer: First Health Commercial |
$9.14
|
| Rate for Payer: Humana Commercial |
$8.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.89
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.47
|
| Rate for Payer: Ohio Health Group HMO |
$7.22
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.98
|
| Rate for Payer: PHCS Commercial |
$9.24
|
| Rate for Payer: United Healthcare All Payer |
$8.47
|
|
