|
XENICAL 120 MG CAPSULE
|
Facility
|
OP
|
$12.82
|
|
|
Service Code
|
NDC 61269046090
|
| Hospital Charge Code |
25001730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$12.31 |
| Rate for Payer: Aetna Commercial |
$9.87
|
| Rate for Payer: Anthem Medicaid |
$4.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.00
|
| Rate for Payer: Cash Price |
$6.41
|
| Rate for Payer: Cigna Commercial |
$10.64
|
| Rate for Payer: First Health Commercial |
$12.18
|
| Rate for Payer: Humana Commercial |
$10.90
|
| Rate for Payer: Humana KY Medicaid |
$4.41
|
| Rate for Payer: Kentucky WC Medicaid |
$4.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.85
|
| Rate for Payer: Molina Healthcare Medicaid |
$4.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.28
|
| Rate for Payer: Ohio Health Group HMO |
$9.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.97
|
| Rate for Payer: PHCS Commercial |
$12.31
|
| Rate for Payer: United Healthcare All Payer |
$11.28
|
|
|
XENICAL 120 MG CAPSULE
|
Facility
|
IP
|
$12.82
|
|
|
Service Code
|
NDC 61269046090
|
| Hospital Charge Code |
25001730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$12.31 |
| Rate for Payer: Aetna Commercial |
$9.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$10.00
|
| Rate for Payer: Cash Price |
$6.41
|
| Rate for Payer: Cigna Commercial |
$10.64
|
| Rate for Payer: First Health Commercial |
$12.18
|
| Rate for Payer: Humana Commercial |
$10.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10.51
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$11.28
|
| Rate for Payer: Ohio Health Group HMO |
$9.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.56
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.97
|
| Rate for Payer: PHCS Commercial |
$12.31
|
| Rate for Payer: United Healthcare All Payer |
$11.28
|
|
|
XENOSURE BIOLOGIC PATCH 2.5*15
|
Facility
|
IP
|
$3,782.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$491.66 |
| Max. Negotiated Rate |
$3,630.72 |
| Rate for Payer: Aetna Commercial |
$2,912.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,949.96
|
| Rate for Payer: Cash Price |
$1,891.00
|
| Rate for Payer: Cigna Commercial |
$3,139.06
|
| Rate for Payer: First Health Commercial |
$3,592.90
|
| Rate for Payer: Humana Commercial |
$3,214.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,101.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,791.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,134.60
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,328.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,836.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$756.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$491.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,172.42
|
| Rate for Payer: PHCS Commercial |
$3,630.72
|
| Rate for Payer: United Healthcare All Payer |
$3,328.16
|
|
|
XENOSURE BIOLOGIC PATCH 2.5*15
|
Facility
|
OP
|
$3,782.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$491.66 |
| Max. Negotiated Rate |
$3,630.72 |
| Rate for Payer: Aetna Commercial |
$2,912.14
|
| Rate for Payer: Anthem Medicaid |
$1,300.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,949.96
|
| Rate for Payer: Cash Price |
$1,891.00
|
| Rate for Payer: Cigna Commercial |
$3,139.06
|
| Rate for Payer: First Health Commercial |
$3,592.90
|
| Rate for Payer: Humana Commercial |
$3,214.70
|
| Rate for Payer: Humana KY Medicaid |
$1,300.63
|
| Rate for Payer: Kentucky WC Medicaid |
$1,313.87
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,101.24
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,791.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,134.60
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,326.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,328.16
|
| Rate for Payer: Ohio Health Group HMO |
$2,836.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$756.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$491.66
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,172.42
|
| Rate for Payer: PHCS Commercial |
$3,630.72
|
| Rate for Payer: United Healthcare All Payer |
$3,328.16
|
|
|
XENOSURE BIOLOGIC PATCH 2*9CM
|
Facility
|
OP
|
$3,320.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$431.60 |
| Max. Negotiated Rate |
$3,187.20 |
| Rate for Payer: Aetna Commercial |
$2,556.40
|
| Rate for Payer: Anthem Medicaid |
$1,141.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,660.00
|
| Rate for Payer: Cigna Commercial |
$2,755.60
|
| Rate for Payer: First Health Commercial |
$3,154.00
|
| Rate for Payer: Humana Commercial |
$2,822.00
|
| Rate for Payer: Humana KY Medicaid |
$1,141.75
|
| Rate for Payer: Kentucky WC Medicaid |
$1,153.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,722.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,164.66
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,921.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$431.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,029.20
|
| Rate for Payer: PHCS Commercial |
$3,187.20
|
| Rate for Payer: United Healthcare All Payer |
$2,921.60
|
|
|
XENOSURE BIOLOGIC PATCH 2*9CM
|
Facility
|
IP
|
$3,320.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$431.60 |
| Max. Negotiated Rate |
$3,187.20 |
| Rate for Payer: Aetna Commercial |
$2,556.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,589.60
|
| Rate for Payer: Cash Price |
$1,660.00
|
| Rate for Payer: Cigna Commercial |
$2,755.60
|
| Rate for Payer: First Health Commercial |
$3,154.00
|
| Rate for Payer: Humana Commercial |
$2,822.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,722.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,450.16
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$996.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,921.60
|
| Rate for Payer: Ohio Health Group HMO |
$2,490.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$664.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$431.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,029.20
|
| Rate for Payer: PHCS Commercial |
$3,187.20
|
| Rate for Payer: United Healthcare All Payer |
$2,921.60
|
|
|
XENOSURE BIOLOGIC PLEDGETS
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem Medicaid |
$7.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Humana KY Medicaid |
$7.91
|
| Rate for Payer: Kentucky WC Medicaid |
$7.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$8.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
XENOSURE BIOLOGIC PLEDGETS
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| Rate for Payer: Aetna Commercial |
$17.71
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Cash Price |
$11.50
|
| Rate for Payer: Cigna Commercial |
$19.09
|
| Rate for Payer: First Health Commercial |
$21.85
|
| Rate for Payer: Humana Commercial |
$19.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$20.24
|
| Rate for Payer: Ohio Health Group HMO |
$17.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7.13
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
X-FUSE IMPLANT LARGE 0 DEG
|
Facility
|
OP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem Medicaid |
$2,751.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Humana KY Medicaid |
$2,751.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
X-FUSE IMPLANT LARGE 0 DEG
|
Facility
|
IP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
X-FUSE IMPLANT LARGE 15 DEG
|
Facility
|
OP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem Medicaid |
$2,751.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Humana KY Medicaid |
$2,751.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
X-FUSE IMPLANT LARGE 15 DEG
|
Facility
|
IP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
X-FUSE IMPLANT LARGE 25 DEG
|
Facility
|
OP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem Medicaid |
$2,751.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Humana KY Medicaid |
$2,751.63
|
| Rate for Payer: Kentucky WC Medicaid |
$2,779.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,806.84
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
X-FUSE IMPLANT LARGE 25 DEG
|
Facility
|
IP
|
$8,001.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,040.16 |
| Max. Negotiated Rate |
$7,681.20 |
| Rate for Payer: Aetna Commercial |
$6,160.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,240.98
|
| Rate for Payer: Cash Price |
$4,000.62
|
| Rate for Payer: Cigna Commercial |
$6,641.04
|
| Rate for Payer: First Health Commercial |
$7,601.19
|
| Rate for Payer: Humana Commercial |
$6,801.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,561.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,904.92
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,400.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,041.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,000.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,600.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,040.16
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,480.39
|
| Rate for Payer: PHCS Commercial |
$7,681.20
|
| Rate for Payer: United Healthcare All Payer |
$7,041.10
|
|
|
X-FUSE IMPLANT SMALL 0 DEG
|
Facility
|
IP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT SMALL 0 DEG
|
Facility
|
OP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem Medicaid |
$2,375.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Humana KY Medicaid |
$2,375.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,399.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT SMALL 15 DEG
|
Facility
|
OP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem Medicaid |
$2,375.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Humana KY Medicaid |
$2,375.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,399.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT SMALL 15 DEG
|
Facility
|
IP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT SMALL 25 DEG
|
Facility
|
IP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT SMALL 25 DEG
|
Facility
|
OP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem Medicaid |
$2,375.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Humana KY Medicaid |
$2,375.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,399.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT STD 0 DEG
|
Facility
|
IP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT STD 0 DEG
|
Facility
|
OP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem Medicaid |
$2,375.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Humana KY Medicaid |
$2,375.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,399.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT STD 15 DEG
|
Facility
|
IP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT STD 15 DEG
|
Facility
|
OP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem Medicaid |
$2,375.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Humana KY Medicaid |
$2,375.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,399.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
|
X-FUSE IMPLANT STD 25 DEG
|
Facility
|
OP
|
$6,906.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$897.81 |
| Max. Negotiated Rate |
$6,630.00 |
| Rate for Payer: Aetna Commercial |
$5,317.81
|
| Rate for Payer: Anthem Medicaid |
$2,375.06
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,386.88
|
| Rate for Payer: Cash Price |
$3,453.12
|
| Rate for Payer: Cigna Commercial |
$5,732.19
|
| Rate for Payer: First Health Commercial |
$6,560.94
|
| Rate for Payer: Humana Commercial |
$5,870.31
|
| Rate for Payer: Humana KY Medicaid |
$2,375.06
|
| Rate for Payer: Kentucky WC Medicaid |
$2,399.23
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,663.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,096.81
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,071.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,422.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,077.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,179.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,381.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$897.81
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,140.94
|
| Rate for Payer: PHCS Commercial |
$6,630.00
|
| Rate for Payer: United Healthcare All Payer |
$6,077.50
|
|
