|
XENICAL 120 MG CAPSULE
|
Facility
|
OP
|
$12.82
|
|
|
Service Code
|
NDC 61269046090
|
| Hospital Charge Code |
25001730
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| 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 |
$10.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.85
|
| 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 |
$3.85 |
| 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 |
$10.26
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8.85
|
| Rate for Payer: PHCS Commercial |
$12.31
|
| Rate for Payer: United Healthcare All Payer |
$11.28
|
|
|
XENOSURE BIOLOGIC PATCH 2.5*15
|
Facility
|
OP
|
$3,908.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.62 |
| Max. Negotiated Rate |
$3,752.40 |
| Rate for Payer: Aetna Commercial |
$3,009.74
|
| Rate for Payer: Anthem Medicaid |
$1,344.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,048.82
|
| Rate for Payer: Cash Price |
$1,954.38
|
| Rate for Payer: Cigna Commercial |
$3,244.26
|
| Rate for Payer: First Health Commercial |
$3,713.31
|
| Rate for Payer: Humana Commercial |
$3,322.44
|
| Rate for Payer: Humana KY Medicaid |
$1,344.22
|
| Rate for Payer: Kentucky WC Medicaid |
$1,357.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,205.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,884.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,172.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,371.19
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,439.70
|
| Rate for Payer: Ohio Health Group HMO |
$2,931.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,127.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,400.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,697.04
|
| Rate for Payer: PHCS Commercial |
$3,752.40
|
| Rate for Payer: United Healthcare All Payer |
$3,439.70
|
|
|
XENOSURE BIOLOGIC PATCH 2.5*15
|
Facility
|
IP
|
$3,908.75
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,172.62 |
| Max. Negotiated Rate |
$3,752.40 |
| Rate for Payer: Aetna Commercial |
$3,009.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,048.82
|
| Rate for Payer: Cash Price |
$1,954.38
|
| Rate for Payer: Cigna Commercial |
$3,244.26
|
| Rate for Payer: First Health Commercial |
$3,713.31
|
| Rate for Payer: Humana Commercial |
$3,322.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,205.18
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,884.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,172.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,439.70
|
| Rate for Payer: Ohio Health Group HMO |
$2,931.56
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,127.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,400.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,697.04
|
| Rate for Payer: PHCS Commercial |
$3,752.40
|
| Rate for Payer: United Healthcare All Payer |
$3,439.70
|
|
|
XENOSURE BIOLOGIC PATCH 2*9CM
|
Facility
|
OP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem Medicaid |
$1,100.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Humana KY Medicaid |
$1,100.48
|
| Rate for Payer: Kentucky WC Medicaid |
$1,111.68
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,122.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
XENOSURE BIOLOGIC PATCH 2*9CM
|
Facility
|
IP
|
$3,200.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$960.00 |
| Max. Negotiated Rate |
$3,072.00 |
| Rate for Payer: Aetna Commercial |
$2,464.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,496.00
|
| Rate for Payer: Cash Price |
$1,600.00
|
| Rate for Payer: Cigna Commercial |
$2,656.00
|
| Rate for Payer: First Health Commercial |
$3,040.00
|
| Rate for Payer: Humana Commercial |
$2,720.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,624.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,361.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$960.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,816.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,400.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,560.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,784.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,208.00
|
| Rate for Payer: PHCS Commercial |
$3,072.00
|
| Rate for Payer: United Healthcare All Payer |
$2,816.00
|
|
|
XENOSURE BIOLOGIC PLEDGETS
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS C1768
|
| Hospital Charge Code |
27000052
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| 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 |
$6.90 |
| 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 |
$18.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$15.87
|
| Rate for Payer: PHCS Commercial |
$22.08
|
| Rate for Payer: United Healthcare All Payer |
$20.24
|
|
|
XEN�� 45 GEL STENT���GLAUCOMA DEV
|
Facility
|
IP
|
$11,023.50
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
27000084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,307.05 |
| Max. Negotiated Rate |
$10,582.56 |
| Rate for Payer: Aetna Commercial |
$8,488.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,598.33
|
| Rate for Payer: Cash Price |
$5,511.75
|
| Rate for Payer: Cigna Commercial |
$9,149.50
|
| Rate for Payer: First Health Commercial |
$10,472.33
|
| Rate for Payer: Humana Commercial |
$9,369.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,039.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,135.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,700.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,267.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,818.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,590.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,606.22
|
| Rate for Payer: PHCS Commercial |
$10,582.56
|
| Rate for Payer: United Healthcare All Payer |
$9,700.68
|
|
|
XEN�� 45 GEL STENT���GLAUCOMA DEV
|
Facility
|
OP
|
$11,023.50
|
|
|
Service Code
|
HCPCS C1783
|
| Hospital Charge Code |
27000084
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,307.05 |
| Max. Negotiated Rate |
$10,582.56 |
| Rate for Payer: Aetna Commercial |
$8,488.09
|
| Rate for Payer: Anthem Medicaid |
$3,790.98
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,598.33
|
| Rate for Payer: Cash Price |
$5,511.75
|
| Rate for Payer: Cigna Commercial |
$9,149.50
|
| Rate for Payer: First Health Commercial |
$10,472.33
|
| Rate for Payer: Humana Commercial |
$9,369.98
|
| Rate for Payer: Humana KY Medicaid |
$3,790.98
|
| Rate for Payer: Kentucky WC Medicaid |
$3,829.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,039.27
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,135.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,307.05
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,867.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,700.68
|
| Rate for Payer: Ohio Health Group HMO |
$8,267.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,818.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$9,590.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,606.22
|
| Rate for Payer: PHCS Commercial |
$10,582.56
|
| Rate for Payer: United Healthcare All Payer |
$9,700.68
|
|
|
X-FUSE IMPLANT LARGE 0 DEG
|
Facility
|
IP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
X-FUSE IMPLANT LARGE 0 DEG
|
Facility
|
OP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem Medicaid |
$2,820.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Humana KY Medicaid |
$2,820.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
X-FUSE IMPLANT LARGE 15 DEG
|
Facility
|
OP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem Medicaid |
$2,820.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Humana KY Medicaid |
$2,820.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
X-FUSE IMPLANT LARGE 15 DEG
|
Facility
|
IP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
X-FUSE IMPLANT LARGE 25 DEG
|
Facility
|
IP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
X-FUSE IMPLANT LARGE 25 DEG
|
Facility
|
OP
|
$8,201.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,460.38 |
| Max. Negotiated Rate |
$7,873.20 |
| Rate for Payer: Aetna Commercial |
$6,314.96
|
| Rate for Payer: Anthem Medicaid |
$2,820.41
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,396.98
|
| Rate for Payer: Cash Price |
$4,100.62
|
| Rate for Payer: Cigna Commercial |
$6,807.04
|
| Rate for Payer: First Health Commercial |
$7,791.19
|
| Rate for Payer: Humana Commercial |
$6,971.06
|
| Rate for Payer: Humana KY Medicaid |
$2,820.41
|
| Rate for Payer: Kentucky WC Medicaid |
$2,849.11
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,725.02
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,052.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,460.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,217.10
|
| Rate for Payer: Ohio Health Group HMO |
$6,150.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,561.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,135.09
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,658.86
|
| Rate for Payer: PHCS Commercial |
$7,873.20
|
| Rate for Payer: United Healthcare All Payer |
$7,217.10
|
|
|
X-FUSE IMPLANT SMALL 0 DEG
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT SMALL 0 DEG
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT SMALL 15 DEG
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT SMALL 15 DEG
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT SMALL 25 DEG
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT SMALL 25 DEG
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT STD 0 DEG
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT STD 0 DEG
|
Facility
|
OP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem Medicaid |
$2,443.84
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Humana KY Medicaid |
$2,443.84
|
| Rate for Payer: Kentucky WC Medicaid |
$2,468.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,492.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
|
X-FUSE IMPLANT STD 15 DEG
|
Facility
|
IP
|
$7,106.25
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,131.88 |
| Max. Negotiated Rate |
$6,822.00 |
| Rate for Payer: Aetna Commercial |
$5,471.81
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$5,542.88
|
| Rate for Payer: Cash Price |
$3,553.12
|
| Rate for Payer: Cigna Commercial |
$5,898.19
|
| Rate for Payer: First Health Commercial |
$6,750.94
|
| Rate for Payer: Humana Commercial |
$6,040.31
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$5,827.12
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$5,244.41
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,131.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$6,253.50
|
| Rate for Payer: Ohio Health Group HMO |
$5,329.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$5,685.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$6,182.44
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,903.31
|
| Rate for Payer: PHCS Commercial |
$6,822.00
|
| Rate for Payer: United Healthcare All Payer |
$6,253.50
|
|
