|
DX LMBR SPI PNXR W/FLUOR/CT (T
|
Facility
|
IP
|
$948.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
360T1289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.24 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$284.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.88
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT (T
|
Facility
|
OP
|
$948.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
761T2742
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.24 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem Medicaid |
$326.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Humana KY Medicaid |
$326.02
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$329.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.88
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
DX LMBR SPI PNXR W/FLUOR/CT (T
|
Facility
|
OP
|
$948.00
|
|
|
Service Code
|
HCPCS 62328
|
| Hospital Charge Code |
360T1289
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$123.24 |
| Max. Negotiated Rate |
$910.08 |
| Rate for Payer: Aetna Commercial |
$729.96
|
| Rate for Payer: Anthem Medicaid |
$326.02
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$598.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$739.44
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$837.23
|
| Rate for Payer: CareSource Just4Me Medicare |
$807.33
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cash Price |
$474.00
|
| Rate for Payer: Cigna Commercial |
$786.84
|
| Rate for Payer: First Health Commercial |
$900.60
|
| Rate for Payer: Humana Commercial |
$805.80
|
| Rate for Payer: Humana KY Medicaid |
$326.02
|
| Rate for Payer: Humana Medicare Advantage |
$598.02
|
| Rate for Payer: Kentucky WC Medicaid |
$329.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$777.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$699.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$717.62
|
| Rate for Payer: Molina Healthcare Medicaid |
$332.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$834.24
|
| Rate for Payer: Ohio Health Group HMO |
$711.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$189.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$123.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.88
|
| Rate for Payer: PHCS Commercial |
$910.08
|
| Rate for Payer: United Healthcare All Payer |
$834.24
|
|
|
DX SWIVELOCK 3.5X8.5MM W/FORKT
|
Facility
|
IP
|
$3,687.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$479.38 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$737.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$479.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,143.12
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
DX SWIVELOCK 3.5X8.5MM W/FORKT
|
Facility
|
OP
|
$3,687.50
|
|
| Hospital Charge Code |
27000242
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$479.38 |
| Max. Negotiated Rate |
$3,540.00 |
| Rate for Payer: Aetna Commercial |
$2,839.38
|
| Rate for Payer: Anthem Medicaid |
$1,268.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,876.25
|
| Rate for Payer: Cash Price |
$1,843.75
|
| Rate for Payer: Cigna Commercial |
$3,060.62
|
| Rate for Payer: First Health Commercial |
$3,503.12
|
| Rate for Payer: Humana Commercial |
$3,134.38
|
| Rate for Payer: Humana KY Medicaid |
$1,268.13
|
| Rate for Payer: Kentucky WC Medicaid |
$1,281.04
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,023.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,721.38
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,106.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,293.58
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,245.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,765.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$737.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$479.38
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,143.12
|
| Rate for Payer: PHCS Commercial |
$3,540.00
|
| Rate for Payer: United Healthcare All Payer |
$3,245.00
|
|
|
DYAZIDE(TRIAMTERENE/HCTZ) 1CAP
|
Facility
|
OP
|
$4.41
|
|
|
Service Code
|
NDC 72578009001
|
| Hospital Charge Code |
25000588
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem Medicaid |
$1.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.66
|
| Rate for Payer: First Health Commercial |
$4.19
|
| Rate for Payer: Humana Commercial |
$3.75
|
| Rate for Payer: Humana KY Medicaid |
$1.52
|
| Rate for Payer: Kentucky WC Medicaid |
$1.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.88
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Payer |
$3.88
|
|
|
DYAZIDE(TRIAMTERENE/HCTZ) 1CAP
|
Facility
|
IP
|
$4.41
|
|
|
Service Code
|
NDC 72578009001
|
| Hospital Charge Code |
25000588
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.57 |
| Max. Negotiated Rate |
$4.23 |
| Rate for Payer: Aetna Commercial |
$3.40
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.44
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna Commercial |
$3.66
|
| Rate for Payer: First Health Commercial |
$4.19
|
| Rate for Payer: Humana Commercial |
$3.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.25
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.32
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.88
|
| Rate for Payer: Ohio Health Group HMO |
$3.31
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.88
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.37
|
| Rate for Payer: PHCS Commercial |
$4.23
|
| Rate for Payer: United Healthcare All Payer |
$3.88
|
|
|
DYE LYMPHAZURIN
|
Facility
|
IP
|
$23.00
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
25003191
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$22.08 |
| 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
|
| 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
|
|
|
DYE LYMPHAZURIN
|
Facility
|
OP
|
$23.00
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
25003191
|
|
Hospital Revenue Code
|
636
|
| 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 Medicare Advantage/PPO |
$7.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.94
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$11.13
|
| Rate for Payer: CareSource Just4Me Medicare |
$10.73
|
| Rate for Payer: Cash Price |
$11.50
|
| 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: Humana Medicare Advantage |
$7.95
|
| 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 |
$9.54
|
| 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
|
|
|
DYNACIRC (ISRADIPIN 2.5MG/1CAP
|
Facility
|
IP
|
$9.44
|
|
|
Service Code
|
NDC 16252053901
|
| Hospital Charge Code |
25003846
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.06 |
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.97
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.31
|
| Rate for Payer: Ohio Health Group HMO |
$7.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$9.06
|
| Rate for Payer: United Healthcare All Payer |
$8.31
|
| Rate for Payer: Aetna Commercial |
$7.27
|
|
|
DYNACIRC (ISRADIPIN 2.5MG/1CAP
|
Facility
|
OP
|
$9.44
|
|
|
Service Code
|
NDC 16252053901
|
| Hospital Charge Code |
25003846
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$9.06 |
| Rate for Payer: Aetna Commercial |
$7.27
|
| Rate for Payer: Anthem Medicaid |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.36
|
| Rate for Payer: Cash Price |
$4.72
|
| Rate for Payer: Cigna Commercial |
$7.84
|
| Rate for Payer: First Health Commercial |
$8.97
|
| Rate for Payer: Humana Commercial |
$8.02
|
| Rate for Payer: Humana KY Medicaid |
$3.25
|
| Rate for Payer: Kentucky WC Medicaid |
$3.28
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.74
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.83
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.31
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.31
|
| Rate for Payer: Ohio Health Group HMO |
$7.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.89
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.23
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.93
|
| Rate for Payer: PHCS Commercial |
$9.06
|
| Rate for Payer: United Healthcare All Payer |
$8.31
|
|
|
DYNACIRC (ISRADIPINE) 5MG CAP
|
Facility
|
OP
|
$10.11
|
|
|
Service Code
|
NDC 16252054001
|
| Hospital Charge Code |
25000589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.71 |
| Rate for Payer: Aetna Commercial |
$7.78
|
| Rate for Payer: Anthem Medicaid |
$3.48
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.89
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Cigna Commercial |
$8.39
|
| Rate for Payer: First Health Commercial |
$9.60
|
| Rate for Payer: Humana Commercial |
$8.59
|
| Rate for Payer: Humana KY Medicaid |
$3.48
|
| Rate for Payer: Kentucky WC Medicaid |
$3.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.03
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.90
|
| Rate for Payer: Ohio Health Group HMO |
$7.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$9.71
|
| Rate for Payer: United Healthcare All Payer |
$8.90
|
|
|
DYNACIRC (ISRADIPINE) 5MG CAP
|
Facility
|
IP
|
$10.11
|
|
|
Service Code
|
NDC 16252054001
|
| Hospital Charge Code |
25000589
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$9.71 |
| Rate for Payer: Humana Commercial |
$8.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8.29
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.90
|
| Rate for Payer: Ohio Health Group HMO |
$7.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2.02
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.13
|
| Rate for Payer: PHCS Commercial |
$9.71
|
| Rate for Payer: United Healthcare All Payer |
$8.90
|
| Rate for Payer: Aetna Commercial |
$7.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.89
|
| Rate for Payer: Cash Price |
$5.06
|
| Rate for Payer: Cigna Commercial |
$8.39
|
| Rate for Payer: First Health Commercial |
$9.60
|
|
|
DYNAFORCE MTP LNG PLATE 5*X0*
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP LNG PLATE 5*X0*
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP PLATE 5*X0*
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP PLATE 5*X0*
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP STD PLATE 0* R/L
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP STD PLATE 0* R/L
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP STD PLATE 10*R/L
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP STD PLATE 10*R/L
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP STD PLATE 5*R/L
|
Facility
|
OP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem Medicaid |
$1,869.96
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Humana KY Medicaid |
$1,869.96
|
| Rate for Payer: Kentucky WC Medicaid |
$1,888.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,907.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
|
|
DYNAFORCE MTP STD PLATE 5*R/L
|
Facility
|
IP
|
$5,437.50
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$706.88 |
| Max. Negotiated Rate |
$5,220.00 |
| Rate for Payer: Humana Commercial |
$4,621.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,458.75
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$4,012.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,631.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,785.00
|
| Rate for Payer: Ohio Health Group HMO |
$4,078.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,087.50
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$706.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,685.62
|
| Rate for Payer: PHCS Commercial |
$5,220.00
|
| Rate for Payer: United Healthcare All Payer |
$4,785.00
|
| Rate for Payer: Aetna Commercial |
$4,186.88
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$4,241.25
|
| Rate for Payer: Cash Price |
$2,718.75
|
| Rate for Payer: Cigna Commercial |
$4,513.12
|
| Rate for Payer: First Health Commercial |
$5,165.62
|
|
|
DYNANAIL MINI 7MM*100MM
|
Facility
|
OP
|
$22,028.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,863.64 |
| Max. Negotiated Rate |
$21,146.88 |
| Rate for Payer: Aetna Commercial |
$16,961.56
|
| Rate for Payer: Anthem Medicaid |
$7,575.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,181.84
|
| Rate for Payer: Cash Price |
$11,014.00
|
| Rate for Payer: Cigna Commercial |
$18,283.24
|
| Rate for Payer: First Health Commercial |
$20,926.60
|
| Rate for Payer: Humana Commercial |
$18,723.80
|
| Rate for Payer: Humana KY Medicaid |
$7,575.43
|
| Rate for Payer: Kentucky WC Medicaid |
$7,652.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,062.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,256.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,608.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$7,727.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,384.64
|
| Rate for Payer: Ohio Health Group HMO |
$16,521.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,405.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,863.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,828.68
|
| Rate for Payer: PHCS Commercial |
$21,146.88
|
| Rate for Payer: United Healthcare All Payer |
$19,384.64
|
|
|
DYNANAIL MINI 7MM*100MM
|
Facility
|
IP
|
$22,028.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,863.64 |
| Max. Negotiated Rate |
$21,146.88 |
| Rate for Payer: Aetna Commercial |
$16,961.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17,181.84
|
| Rate for Payer: Cash Price |
$11,014.00
|
| Rate for Payer: Cigna Commercial |
$18,283.24
|
| Rate for Payer: First Health Commercial |
$20,926.60
|
| Rate for Payer: Humana Commercial |
$18,723.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18,062.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16,256.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6,608.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$19,384.64
|
| Rate for Payer: Ohio Health Group HMO |
$16,521.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,405.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,863.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,828.68
|
| Rate for Payer: PHCS Commercial |
$21,146.88
|
| Rate for Payer: United Healthcare All Payer |
$19,384.64
|
|
