|
BEYFORTUS50MG/0.5MLSDV
|
Professional
|
Both
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
77000096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$369.95 |
| Max. Negotiated Rate |
$739.90 |
| Rate for Payer: Anthem Medicaid |
$485.10
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Humana Medicaid |
$485.10
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$494.80
|
| Rate for Payer: Molina Healthcare Passport |
$485.10
|
| Rate for Payer: Multiplan PHCS |
$634.20
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$739.90
|
| Rate for Payer: UHCCP Medicaid |
$369.95
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$489.95
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
77000096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.10 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem Medicaid |
$363.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Humana KY Medicaid |
$363.50
|
| Rate for Payer: Kentucky WC Medicaid |
$367.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$845.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$919.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$729.33
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
OP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
770T0096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.10 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem Medicaid |
$363.50
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Humana KY Medicaid |
$363.50
|
| Rate for Payer: Kentucky WC Medicaid |
$367.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Molina Healthcare Medicaid |
$370.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$845.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$919.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$729.33
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BEYFORTUS50MG/0.5MLSDV
|
Facility
|
IP
|
$1,057.00
|
|
|
Service Code
|
HCPCS 90380
|
| Hospital Charge Code |
770T0096
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$317.10 |
| Max. Negotiated Rate |
$1,014.72 |
| Rate for Payer: Aetna Commercial |
$813.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$824.46
|
| Rate for Payer: Cash Price |
$528.50
|
| Rate for Payer: Cigna Commercial |
$877.31
|
| Rate for Payer: First Health Commercial |
$1,004.15
|
| Rate for Payer: Humana Commercial |
$898.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$866.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$780.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$317.10
|
| Rate for Payer: Ohio Health Choice Commercial |
$930.16
|
| Rate for Payer: Ohio Health Group HMO |
$792.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$845.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$919.59
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$729.33
|
| Rate for Payer: PHCS Commercial |
$1,014.72
|
| Rate for Payer: United Healthcare All Payer |
$930.16
|
|
|
BF 40MM KLD GLENOD W/46MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 40MM KLD GLENOD W/46MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 40MM PEG GLENOD W/46MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 40MM PEG GLENOD W/46MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM KLD GLENOD W/40MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM KLD GLENOD W/40MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM KLD GLENOD W/52MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM KLD GLENOD W/52MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM PEG GLENOD W/40MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM PEG GLENOD W/40MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM PEG GLENOD W/52MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 46MM PEG GLENOD W/52MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM KLD GLENOD W/46MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM KLD GLENOD W/46MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM KLD GLENOD W/56MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM KLD GLENOD W/56MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM PEG GLENOD W/46MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM PEG GLENOD W/46MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM PEG GLENOD W/56MM SURF
|
Facility
|
IP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF 52MM PEG GLENOD W/56MM SURF
|
Facility
|
OP
|
$9,359.76
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,807.93 |
| Max. Negotiated Rate |
$8,985.37 |
| Rate for Payer: Aetna Commercial |
$7,207.02
|
| Rate for Payer: Anthem Medicaid |
$3,218.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,300.61
|
| Rate for Payer: Cash Price |
$4,679.88
|
| Rate for Payer: Cigna Commercial |
$7,768.60
|
| Rate for Payer: First Health Commercial |
$8,891.77
|
| Rate for Payer: Humana Commercial |
$7,955.80
|
| Rate for Payer: Humana KY Medicaid |
$3,218.82
|
| Rate for Payer: Kentucky WC Medicaid |
$3,251.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,675.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,907.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,807.93
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,283.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,236.59
|
| Rate for Payer: Ohio Health Group HMO |
$7,019.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,487.81
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,142.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,458.23
|
| Rate for Payer: PHCS Commercial |
$8,985.37
|
| Rate for Payer: United Healthcare All Payer |
$8,236.59
|
|
|
BF ANAT SHOULDR ADAPTOR 42 DEG
|
Facility
|
IP
|
$8,329.00
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,498.70 |
| Max. Negotiated Rate |
$7,995.84 |
| Rate for Payer: Aetna Commercial |
$6,413.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,496.62
|
| Rate for Payer: Cash Price |
$4,164.50
|
| Rate for Payer: Cigna Commercial |
$6,913.07
|
| Rate for Payer: First Health Commercial |
$7,912.55
|
| Rate for Payer: Humana Commercial |
$7,079.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,829.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,146.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,498.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,329.52
|
| Rate for Payer: Ohio Health Group HMO |
$6,246.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,663.20
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,246.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,747.01
|
| Rate for Payer: PHCS Commercial |
$7,995.84
|
| Rate for Payer: United Healthcare All Payer |
$7,329.52
|
|
