|
TRICOR FENOFIBRATE 145 MG TAB
|
Facility
|
IP
|
$4.85
|
|
|
Service Code
|
NDC 378306677
|
| Hospital Charge Code |
25001593
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.78
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna Commercial |
$4.03
|
| Rate for Payer: First Health Commercial |
$4.61
|
| Rate for Payer: Humana Commercial |
$4.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.27
|
| Rate for Payer: Ohio Health Group HMO |
$3.64
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.97
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.50
|
| Rate for Payer: PHCS Commercial |
$4.66
|
| Rate for Payer: United Healthcare All Payer |
$4.27
|
|
|
TRICOR(FENOFIBRATE)48MG TAB
|
Facility
|
OP
|
$4.31
|
|
|
Service Code
|
NDC 65862076890
|
| Hospital Charge Code |
25001594
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem Medicaid |
$1.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Humana KY Medicaid |
$1.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.51
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
TRICOR(FENOFIBRATE)48MG TAB
|
Facility
|
IP
|
$4.31
|
|
|
Service Code
|
NDC 65862076890
|
| Hospital Charge Code |
25001594
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$4.14 |
| Rate for Payer: Aetna Commercial |
$3.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.36
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cigna Commercial |
$3.58
|
| Rate for Payer: First Health Commercial |
$4.09
|
| Rate for Payer: Humana Commercial |
$3.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.53
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.18
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.79
|
| Rate for Payer: Ohio Health Group HMO |
$3.23
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.56
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.34
|
| Rate for Payer: PHCS Commercial |
$4.14
|
| Rate for Payer: United Healthcare All Payer |
$3.79
|
|
|
TRIDENT 0^ CONSTRAINED INSERT
|
Facility
|
IP
|
$15,189.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,974.62 |
| Max. Negotiated Rate |
$14,581.82 |
| Rate for Payer: Aetna Commercial |
$11,695.84
|
| Rate for Payer: Aetna Commercial |
$11,781.29
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,847.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,934.30
|
| Rate for Payer: Cash Price |
$7,594.70
|
| Rate for Payer: Cash Price |
$7,650.19
|
| Rate for Payer: Cigna Commercial |
$12,607.20
|
| Rate for Payer: Cigna Commercial |
$12,699.32
|
| Rate for Payer: First Health Commercial |
$14,535.36
|
| Rate for Payer: First Health Commercial |
$14,429.93
|
| Rate for Payer: Humana Commercial |
$13,005.32
|
| Rate for Payer: Humana Commercial |
$12,910.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,455.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,546.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,209.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,291.68
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,590.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,556.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,366.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,464.33
|
| Rate for Payer: Ohio Health Group HMO |
$11,392.05
|
| Rate for Payer: Ohio Health Group HMO |
$11,475.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,037.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,060.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,974.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,989.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,743.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,708.71
|
| Rate for Payer: PHCS Commercial |
$14,581.82
|
| Rate for Payer: PHCS Commercial |
$14,688.36
|
| Rate for Payer: United Healthcare All Payer |
$13,366.67
|
| Rate for Payer: United Healthcare All Payer |
$13,464.33
|
|
|
TRIDENT 0^ CONSTRAINED INSERT
|
Facility
|
OP
|
$15,189.40
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,974.62 |
| Max. Negotiated Rate |
$14,581.82 |
| Rate for Payer: Aetna Commercial |
$11,695.84
|
| Rate for Payer: Aetna Commercial |
$11,781.29
|
| Rate for Payer: Anthem Medicaid |
$5,223.63
|
| Rate for Payer: Anthem Medicaid |
$5,261.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,847.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$11,934.30
|
| Rate for Payer: Cash Price |
$7,594.70
|
| Rate for Payer: Cash Price |
$7,650.19
|
| Rate for Payer: Cigna Commercial |
$12,699.32
|
| Rate for Payer: Cigna Commercial |
$12,607.20
|
| Rate for Payer: First Health Commercial |
$14,535.36
|
| Rate for Payer: First Health Commercial |
$14,429.93
|
| Rate for Payer: Humana Commercial |
$12,910.99
|
| Rate for Payer: Humana Commercial |
$13,005.32
|
| Rate for Payer: Humana KY Medicaid |
$5,223.63
|
| Rate for Payer: Humana KY Medicaid |
$5,261.80
|
| Rate for Payer: Kentucky WC Medicaid |
$5,315.35
|
| Rate for Payer: Kentucky WC Medicaid |
$5,276.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,455.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,546.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,291.68
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,209.78
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,590.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,556.82
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,328.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,367.37
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,366.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,464.33
|
| Rate for Payer: Ohio Health Group HMO |
$11,392.05
|
| Rate for Payer: Ohio Health Group HMO |
$11,475.28
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,037.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,060.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,974.62
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,989.05
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,708.71
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,743.12
|
| Rate for Payer: PHCS Commercial |
$14,688.36
|
| Rate for Payer: PHCS Commercial |
$14,581.82
|
| Rate for Payer: United Healthcare All Payer |
$13,464.33
|
| Rate for Payer: United Healthcare All Payer |
$13,366.67
|
|
|
TRIDENT 0^ CONSTRAINED INSRT E
|
Facility
|
OP
|
$17,024.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,213.16 |
| Max. Negotiated Rate |
$16,343.31 |
| Rate for Payer: Aetna Commercial |
$13,108.70
|
| Rate for Payer: Anthem Medicaid |
$5,854.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,278.94
|
| Rate for Payer: Cash Price |
$8,512.14
|
| Rate for Payer: Cigna Commercial |
$14,130.15
|
| Rate for Payer: First Health Commercial |
$16,173.07
|
| Rate for Payer: Humana Commercial |
$14,470.64
|
| Rate for Payer: Humana KY Medicaid |
$5,854.65
|
| Rate for Payer: Kentucky WC Medicaid |
$5,914.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,959.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,563.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,107.28
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,972.12
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,981.37
|
| Rate for Payer: Ohio Health Group HMO |
$12,768.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,404.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,213.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,277.53
|
| Rate for Payer: PHCS Commercial |
$16,343.31
|
| Rate for Payer: United Healthcare All Payer |
$14,981.37
|
|
|
TRIDENT 0^ CONSTRAINED INSRT E
|
Facility
|
IP
|
$17,024.28
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,213.16 |
| Max. Negotiated Rate |
$16,343.31 |
| Rate for Payer: Aetna Commercial |
$13,108.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$13,278.94
|
| Rate for Payer: Cash Price |
$8,512.14
|
| Rate for Payer: Cigna Commercial |
$14,130.15
|
| Rate for Payer: First Health Commercial |
$16,173.07
|
| Rate for Payer: Humana Commercial |
$14,470.64
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,959.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,563.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5,107.28
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,981.37
|
| Rate for Payer: Ohio Health Group HMO |
$12,768.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,404.86
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,213.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,277.53
|
| Rate for Payer: PHCS Commercial |
$16,343.31
|
| Rate for Payer: United Healthcare All Payer |
$14,981.37
|
|
|
TRIDENT 0^ CONSTRAINED INSRT G
|
Facility
|
IP
|
$13,648.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.30 |
| Max. Negotiated Rate |
$13,102.54 |
| Rate for Payer: Aetna Commercial |
$10,509.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.81
|
| Rate for Payer: Cash Price |
$6,824.24
|
| Rate for Payer: Cigna Commercial |
$11,328.24
|
| Rate for Payer: First Health Commercial |
$12,966.06
|
| Rate for Payer: Humana Commercial |
$11,601.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.66
|
| Rate for Payer: Ohio Health Group HMO |
$10,236.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,231.03
|
| Rate for Payer: PHCS Commercial |
$13,102.54
|
| Rate for Payer: United Healthcare All Payer |
$12,010.66
|
|
|
TRIDENT 0^ CONSTRAINED INSRT G
|
Facility
|
OP
|
$13,648.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.30 |
| Max. Negotiated Rate |
$13,102.54 |
| Rate for Payer: Aetna Commercial |
$10,509.33
|
| Rate for Payer: Anthem Medicaid |
$4,693.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.81
|
| Rate for Payer: Cash Price |
$6,824.24
|
| Rate for Payer: Cigna Commercial |
$11,328.24
|
| Rate for Payer: First Health Commercial |
$12,966.06
|
| Rate for Payer: Humana Commercial |
$11,601.21
|
| Rate for Payer: Humana KY Medicaid |
$4,693.71
|
| Rate for Payer: Kentucky WC Medicaid |
$4,741.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,787.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.66
|
| Rate for Payer: Ohio Health Group HMO |
$10,236.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,231.03
|
| Rate for Payer: PHCS Commercial |
$13,102.54
|
| Rate for Payer: United Healthcare All Payer |
$12,010.66
|
|
|
TRIDENT 0^ CONSTRAINED INSRT H
|
Facility
|
IP
|
$15,786.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,052.21 |
| Max. Negotiated Rate |
$15,154.79 |
| Rate for Payer: Aetna Commercial |
$12,155.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,313.27
|
| Rate for Payer: Cash Price |
$7,893.12
|
| Rate for Payer: Cigna Commercial |
$13,102.58
|
| Rate for Payer: First Health Commercial |
$14,996.93
|
| Rate for Payer: Humana Commercial |
$13,418.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,944.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,650.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,735.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,891.89
|
| Rate for Payer: Ohio Health Group HMO |
$11,839.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,157.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,052.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,893.73
|
| Rate for Payer: PHCS Commercial |
$15,154.79
|
| Rate for Payer: United Healthcare All Payer |
$13,891.89
|
|
|
TRIDENT 0^ CONSTRAINED INSRT H
|
Facility
|
OP
|
$15,786.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,052.21 |
| Max. Negotiated Rate |
$15,154.79 |
| Rate for Payer: Aetna Commercial |
$12,155.40
|
| Rate for Payer: Anthem Medicaid |
$5,428.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,313.27
|
| Rate for Payer: Cash Price |
$7,893.12
|
| Rate for Payer: Cigna Commercial |
$13,102.58
|
| Rate for Payer: First Health Commercial |
$14,996.93
|
| Rate for Payer: Humana Commercial |
$13,418.30
|
| Rate for Payer: Humana KY Medicaid |
$5,428.89
|
| Rate for Payer: Kentucky WC Medicaid |
$5,484.14
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,944.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,650.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,735.87
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,537.81
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,891.89
|
| Rate for Payer: Ohio Health Group HMO |
$11,839.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,157.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,052.21
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,893.73
|
| Rate for Payer: PHCS Commercial |
$15,154.79
|
| Rate for Payer: United Healthcare All Payer |
$13,891.89
|
|
|
TRIDENT 0^ CONSTRAINED INSRT I
|
Facility
|
OP
|
$13,648.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.30 |
| Max. Negotiated Rate |
$13,102.54 |
| Rate for Payer: Aetna Commercial |
$10,509.33
|
| Rate for Payer: Anthem Medicaid |
$4,693.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.81
|
| Rate for Payer: Cash Price |
$6,824.24
|
| Rate for Payer: Cigna Commercial |
$11,328.24
|
| Rate for Payer: First Health Commercial |
$12,966.06
|
| Rate for Payer: Humana Commercial |
$11,601.21
|
| Rate for Payer: Humana KY Medicaid |
$4,693.71
|
| Rate for Payer: Kentucky WC Medicaid |
$4,741.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,787.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.66
|
| Rate for Payer: Ohio Health Group HMO |
$10,236.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,231.03
|
| Rate for Payer: PHCS Commercial |
$13,102.54
|
| Rate for Payer: United Healthcare All Payer |
$12,010.66
|
|
|
TRIDENT 0^ CONSTRAINED INSRT I
|
Facility
|
IP
|
$13,648.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.30 |
| Max. Negotiated Rate |
$13,102.54 |
| Rate for Payer: Aetna Commercial |
$10,509.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.81
|
| Rate for Payer: Cash Price |
$6,824.24
|
| Rate for Payer: Cigna Commercial |
$11,328.24
|
| Rate for Payer: First Health Commercial |
$12,966.06
|
| Rate for Payer: Humana Commercial |
$11,601.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.66
|
| Rate for Payer: Ohio Health Group HMO |
$10,236.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,231.03
|
| Rate for Payer: PHCS Commercial |
$13,102.54
|
| Rate for Payer: United Healthcare All Payer |
$12,010.66
|
|
|
TRIDENT 0^ CONSTRAINED INSRT J
|
Facility
|
IP
|
$13,648.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.30 |
| Max. Negotiated Rate |
$13,102.54 |
| Rate for Payer: Aetna Commercial |
$10,509.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.81
|
| Rate for Payer: Cash Price |
$6,824.24
|
| Rate for Payer: Cigna Commercial |
$11,328.24
|
| Rate for Payer: First Health Commercial |
$12,966.06
|
| Rate for Payer: Humana Commercial |
$11,601.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.66
|
| Rate for Payer: Ohio Health Group HMO |
$10,236.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,231.03
|
| Rate for Payer: PHCS Commercial |
$13,102.54
|
| Rate for Payer: United Healthcare All Payer |
$12,010.66
|
|
|
TRIDENT 0^ CONSTRAINED INSRT J
|
Facility
|
OP
|
$13,648.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,774.30 |
| Max. Negotiated Rate |
$13,102.54 |
| Rate for Payer: Aetna Commercial |
$10,509.33
|
| Rate for Payer: Anthem Medicaid |
$4,693.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10,645.81
|
| Rate for Payer: Cash Price |
$6,824.24
|
| Rate for Payer: Cigna Commercial |
$11,328.24
|
| Rate for Payer: First Health Commercial |
$12,966.06
|
| Rate for Payer: Humana Commercial |
$11,601.21
|
| Rate for Payer: Humana KY Medicaid |
$4,693.71
|
| Rate for Payer: Kentucky WC Medicaid |
$4,741.48
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$11,191.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$10,072.58
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,094.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,787.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$12,010.66
|
| Rate for Payer: Ohio Health Group HMO |
$10,236.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,729.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,774.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,231.03
|
| Rate for Payer: PHCS Commercial |
$13,102.54
|
| Rate for Payer: United Healthcare All Payer |
$12,010.66
|
|
|
TRIDENT 0 X3 INSERT 28MM C
|
Facility
|
OP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem Medicaid |
$2,952.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Humana KY Medicaid |
$2,952.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,982.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,011.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM C
|
Facility
|
IP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM D
|
Facility
|
IP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM D
|
Facility
|
OP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem Medicaid |
$2,952.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Humana KY Medicaid |
$2,952.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,982.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,011.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM E
|
Facility
|
OP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem Medicaid |
$2,952.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Humana KY Medicaid |
$2,952.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,982.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,011.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM E
|
Facility
|
IP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM F
|
Facility
|
OP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem Medicaid |
$2,952.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Humana KY Medicaid |
$2,952.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,982.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,011.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM F
|
Facility
|
IP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM G
|
Facility
|
IP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
|
TRIDENT 0 X3 INSERT 28MM G
|
Facility
|
OP
|
$8,584.52
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,115.99 |
| Max. Negotiated Rate |
$8,241.14 |
| Rate for Payer: Aetna Commercial |
$6,610.08
|
| Rate for Payer: Anthem Medicaid |
$2,952.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,695.93
|
| Rate for Payer: Cash Price |
$4,292.26
|
| Rate for Payer: Cigna Commercial |
$7,125.15
|
| Rate for Payer: First Health Commercial |
$8,155.29
|
| Rate for Payer: Humana Commercial |
$7,296.84
|
| Rate for Payer: Humana KY Medicaid |
$2,952.22
|
| Rate for Payer: Kentucky WC Medicaid |
$2,982.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,039.31
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,335.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,575.36
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,011.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,554.38
|
| Rate for Payer: Ohio Health Group HMO |
$6,438.39
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,716.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,115.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,661.20
|
| Rate for Payer: PHCS Commercial |
$8,241.14
|
| Rate for Payer: United Healthcare All Payer |
$7,554.38
|
|
