|
GNS II POR TIB SZ 7 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 8 LEFT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 8 LEFT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 8 RIGHT
|
Facility
|
OP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem Medicaid |
$2,831.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Humana KY Medicaid |
$2,831.34
|
| Rate for Payer: Kentucky WC Medicaid |
$2,860.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,888.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II POR TIB SZ 8 RIGHT
|
Facility
|
IP
|
$8,233.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,070.29 |
| Max. Negotiated Rate |
$7,903.70 |
| Rate for Payer: Aetna Commercial |
$6,339.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,421.76
|
| Rate for Payer: Cash Price |
$4,116.51
|
| Rate for Payer: Cigna Commercial |
$6,833.41
|
| Rate for Payer: First Health Commercial |
$7,821.37
|
| Rate for Payer: Humana Commercial |
$6,998.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,751.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,075.97
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,469.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,245.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,174.76
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,646.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,070.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,552.24
|
| Rate for Payer: PHCS Commercial |
$7,903.70
|
| Rate for Payer: United Healthcare All Payer |
$7,245.06
|
|
|
GNS II RESURF PAT 26MM
|
Facility
|
IP
|
$4,691.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$609.85 |
| Max. Negotiated Rate |
$4,503.48 |
| Rate for Payer: Aetna Commercial |
$3,612.16
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,659.07
|
| Rate for Payer: Cash Price |
$2,345.56
|
| Rate for Payer: Cigna Commercial |
$3,893.63
|
| Rate for Payer: First Health Commercial |
$4,456.56
|
| Rate for Payer: Humana Commercial |
$3,987.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,846.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,462.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,407.34
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,128.19
|
| Rate for Payer: Ohio Health Group HMO |
$3,518.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$938.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,454.25
|
| Rate for Payer: PHCS Commercial |
$4,503.48
|
| Rate for Payer: United Healthcare All Payer |
$4,128.19
|
|
|
GNS II RESURF PAT 26MM
|
Facility
|
OP
|
$4,691.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$609.85 |
| Max. Negotiated Rate |
$4,503.48 |
| Rate for Payer: Aetna Commercial |
$3,612.16
|
| Rate for Payer: Anthem Medicaid |
$1,613.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,659.07
|
| Rate for Payer: Cash Price |
$2,345.56
|
| Rate for Payer: Cigna Commercial |
$3,893.63
|
| Rate for Payer: First Health Commercial |
$4,456.56
|
| Rate for Payer: Humana Commercial |
$3,987.45
|
| Rate for Payer: Humana KY Medicaid |
$1,613.28
|
| Rate for Payer: Kentucky WC Medicaid |
$1,629.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,846.72
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,462.05
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,407.34
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,645.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,128.19
|
| Rate for Payer: Ohio Health Group HMO |
$3,518.34
|
| Rate for Payer: Ohio Health Group PPO Differential |
$938.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$609.85
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,454.25
|
| Rate for Payer: PHCS Commercial |
$4,503.48
|
| Rate for Payer: United Healthcare All Payer |
$4,128.19
|
|
|
GOLDENBERG CAP PROSTHESIS 1.5L
|
Facility
|
IP
|
$3,473.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.57 |
| Max. Negotiated Rate |
$3,334.67 |
| Rate for Payer: Aetna Commercial |
$2,674.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,709.42
|
| Rate for Payer: Cash Price |
$1,736.81
|
| Rate for Payer: Cigna Commercial |
$2,883.10
|
| Rate for Payer: First Health Commercial |
$3,299.93
|
| Rate for Payer: Humana Commercial |
$2,952.57
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,848.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,563.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,042.08
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,056.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,605.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$694.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,076.82
|
| Rate for Payer: PHCS Commercial |
$3,334.67
|
| Rate for Payer: United Healthcare All Payer |
$3,056.78
|
|
|
GOLDENBERG CAP PROSTHESIS 1.5L
|
Facility
|
OP
|
$3,473.61
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$451.57 |
| Max. Negotiated Rate |
$3,334.67 |
| Rate for Payer: Aetna Commercial |
$2,674.68
|
| Rate for Payer: Anthem Medicaid |
$1,194.57
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,709.42
|
| Rate for Payer: Cash Price |
$1,736.81
|
| Rate for Payer: Cigna Commercial |
$2,883.10
|
| Rate for Payer: First Health Commercial |
$3,299.93
|
| Rate for Payer: Humana Commercial |
$2,952.57
|
| Rate for Payer: Humana KY Medicaid |
$1,194.57
|
| Rate for Payer: Kentucky WC Medicaid |
$1,206.73
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,848.36
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,563.52
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,042.08
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,218.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,056.78
|
| Rate for Payer: Ohio Health Group HMO |
$2,605.21
|
| Rate for Payer: Ohio Health Group PPO Differential |
$694.72
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$451.57
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,076.82
|
| Rate for Payer: PHCS Commercial |
$3,334.67
|
| Rate for Payer: United Healthcare All Payer |
$3,056.78
|
|
|
GOLDENBERG INCUS PROST 4.2 L
|
Facility
|
IP
|
$3,614.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$3,470.11 |
| Rate for Payer: Aetna Commercial |
$2,783.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,819.47
|
| Rate for Payer: Cash Price |
$1,807.35
|
| Rate for Payer: Cigna Commercial |
$3,000.20
|
| Rate for Payer: First Health Commercial |
$3,433.96
|
| Rate for Payer: Humana Commercial |
$3,072.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,964.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,667.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,084.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,180.94
|
| Rate for Payer: Ohio Health Group HMO |
$2,711.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,120.56
|
| Rate for Payer: PHCS Commercial |
$3,470.11
|
| Rate for Payer: United Healthcare All Payer |
$3,180.94
|
|
|
GOLDENBERG INCUS PROST 4.2 L
|
Facility
|
OP
|
$3,614.70
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$469.91 |
| Max. Negotiated Rate |
$3,470.11 |
| Rate for Payer: Aetna Commercial |
$2,783.32
|
| Rate for Payer: Anthem Medicaid |
$1,243.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,819.47
|
| Rate for Payer: Cash Price |
$1,807.35
|
| Rate for Payer: Cigna Commercial |
$3,000.20
|
| Rate for Payer: First Health Commercial |
$3,433.96
|
| Rate for Payer: Humana Commercial |
$3,072.50
|
| Rate for Payer: Humana KY Medicaid |
$1,243.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,255.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,964.05
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,667.65
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,084.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,268.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,180.94
|
| Rate for Payer: Ohio Health Group HMO |
$2,711.02
|
| Rate for Payer: Ohio Health Group PPO Differential |
$722.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$469.91
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,120.56
|
| Rate for Payer: PHCS Commercial |
$3,470.11
|
| Rate for Payer: United Healthcare All Payer |
$3,180.94
|
|
|
GOLDENBERG INCUS PROST 8.2 L
|
Facility
|
IP
|
$3,525.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$458.28 |
| Max. Negotiated Rate |
$3,384.23 |
| Rate for Payer: Aetna Commercial |
$2,714.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,749.69
|
| Rate for Payer: Cash Price |
$1,762.62
|
| Rate for Payer: Cigna Commercial |
$2,925.95
|
| Rate for Payer: First Health Commercial |
$3,348.98
|
| Rate for Payer: Humana Commercial |
$2,996.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,890.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,601.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,057.57
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,102.21
|
| Rate for Payer: Ohio Health Group HMO |
$2,643.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$705.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,092.82
|
| Rate for Payer: PHCS Commercial |
$3,384.23
|
| Rate for Payer: United Healthcare All Payer |
$3,102.21
|
|
|
GOLDENBERG INCUS PROST 8.2 L
|
Facility
|
OP
|
$3,525.24
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$458.28 |
| Max. Negotiated Rate |
$3,384.23 |
| Rate for Payer: Aetna Commercial |
$2,714.43
|
| Rate for Payer: Anthem Medicaid |
$1,212.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,749.69
|
| Rate for Payer: Cash Price |
$1,762.62
|
| Rate for Payer: Cigna Commercial |
$2,925.95
|
| Rate for Payer: First Health Commercial |
$3,348.98
|
| Rate for Payer: Humana Commercial |
$2,996.45
|
| Rate for Payer: Humana KY Medicaid |
$1,212.33
|
| Rate for Payer: Kentucky WC Medicaid |
$1,224.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,890.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,601.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,057.57
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,236.65
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,102.21
|
| Rate for Payer: Ohio Health Group HMO |
$2,643.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$705.05
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$458.28
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,092.82
|
| Rate for Payer: PHCS Commercial |
$3,384.23
|
| Rate for Payer: United Healthcare All Payer |
$3,102.21
|
|
|
GOLDENBERG MALLEABLE PORP 5.1L
|
Facility
|
IP
|
$3,628.21
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.67 |
| Max. Negotiated Rate |
$3,483.08 |
| Rate for Payer: Aetna Commercial |
$2,793.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,830.00
|
| Rate for Payer: Cash Price |
$1,814.11
|
| Rate for Payer: Cigna Commercial |
$3,011.41
|
| Rate for Payer: First Health Commercial |
$3,446.80
|
| Rate for Payer: Humana Commercial |
$3,083.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,975.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,677.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,088.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,192.82
|
| Rate for Payer: Ohio Health Group HMO |
$2,721.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$725.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$471.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,124.75
|
| Rate for Payer: PHCS Commercial |
$3,483.08
|
| Rate for Payer: United Healthcare All Payer |
$3,192.82
|
|
|
GOLDENBERG MALLEABLE PORP 5.1L
|
Facility
|
OP
|
$3,628.21
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$471.67 |
| Max. Negotiated Rate |
$3,483.08 |
| Rate for Payer: Aetna Commercial |
$2,793.72
|
| Rate for Payer: Anthem Medicaid |
$1,247.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,830.00
|
| Rate for Payer: Cash Price |
$1,814.11
|
| Rate for Payer: Cigna Commercial |
$3,011.41
|
| Rate for Payer: First Health Commercial |
$3,446.80
|
| Rate for Payer: Humana Commercial |
$3,083.98
|
| Rate for Payer: Humana KY Medicaid |
$1,247.74
|
| Rate for Payer: Kentucky WC Medicaid |
$1,260.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,975.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,677.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,088.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,272.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,192.82
|
| Rate for Payer: Ohio Health Group HMO |
$2,721.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$725.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$471.67
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,124.75
|
| Rate for Payer: PHCS Commercial |
$3,483.08
|
| Rate for Payer: United Healthcare All Payer |
$3,192.82
|
|
|
GOLDENBERG PORP PROST 5.5 L
|
Facility
|
OP
|
$3,667.66
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$476.80 |
| Max. Negotiated Rate |
$3,520.95 |
| Rate for Payer: Aetna Commercial |
$2,824.10
|
| Rate for Payer: Anthem Medicaid |
$1,261.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,860.77
|
| Rate for Payer: Cash Price |
$1,833.83
|
| Rate for Payer: Cigna Commercial |
$3,044.16
|
| Rate for Payer: First Health Commercial |
$3,484.28
|
| Rate for Payer: Humana Commercial |
$3,117.51
|
| Rate for Payer: Humana KY Medicaid |
$1,261.31
|
| Rate for Payer: Kentucky WC Medicaid |
$1,274.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,007.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,706.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,100.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,286.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,227.54
|
| Rate for Payer: Ohio Health Group HMO |
$2,750.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$733.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,136.97
|
| Rate for Payer: PHCS Commercial |
$3,520.95
|
| Rate for Payer: United Healthcare All Payer |
$3,227.54
|
|
|
GOLDENBERG PORP PROST 5.5 L
|
Facility
|
IP
|
$3,667.66
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$476.80 |
| Max. Negotiated Rate |
$3,520.95 |
| Rate for Payer: Aetna Commercial |
$2,824.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,860.77
|
| Rate for Payer: Cash Price |
$1,833.83
|
| Rate for Payer: Cigna Commercial |
$3,044.16
|
| Rate for Payer: First Health Commercial |
$3,484.28
|
| Rate for Payer: Humana Commercial |
$3,117.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,007.48
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,706.73
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,100.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,227.54
|
| Rate for Payer: Ohio Health Group HMO |
$2,750.74
|
| Rate for Payer: Ohio Health Group PPO Differential |
$733.53
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$476.80
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,136.97
|
| Rate for Payer: PHCS Commercial |
$3,520.95
|
| Rate for Payer: United Healthcare All Payer |
$3,227.54
|
|
|
GOLDENBERG TORP PROST 8.0 L
|
Facility
|
OP
|
$3,647.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$474.13 |
| Max. Negotiated Rate |
$3,501.25 |
| Rate for Payer: Aetna Commercial |
$2,808.30
|
| Rate for Payer: Anthem Medicaid |
$1,254.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,844.77
|
| Rate for Payer: Cash Price |
$1,823.57
|
| Rate for Payer: Cigna Commercial |
$3,027.13
|
| Rate for Payer: First Health Commercial |
$3,464.78
|
| Rate for Payer: Humana Commercial |
$3,100.07
|
| Rate for Payer: Humana KY Medicaid |
$1,254.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,267.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,990.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,691.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,094.14
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,279.42
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,209.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,735.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$729.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$474.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,130.61
|
| Rate for Payer: PHCS Commercial |
$3,501.25
|
| Rate for Payer: United Healthcare All Payer |
$3,209.48
|
|
|
GOLDENBERG TORP PROST 8.0 L
|
Facility
|
IP
|
$3,647.14
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$474.13 |
| Max. Negotiated Rate |
$3,501.25 |
| Rate for Payer: Aetna Commercial |
$2,808.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,844.77
|
| Rate for Payer: Cash Price |
$1,823.57
|
| Rate for Payer: Cigna Commercial |
$3,027.13
|
| Rate for Payer: First Health Commercial |
$3,464.78
|
| Rate for Payer: Humana Commercial |
$3,100.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,990.65
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,691.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,094.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,209.48
|
| Rate for Payer: Ohio Health Group HMO |
$2,735.36
|
| Rate for Payer: Ohio Health Group PPO Differential |
$729.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$474.13
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,130.61
|
| Rate for Payer: PHCS Commercial |
$3,501.25
|
| Rate for Payer: United Healthcare All Payer |
$3,209.48
|
|
|
GOLDWIRE 300CM
|
Facility
|
OP
|
$1,948.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.30 |
| Max. Negotiated Rate |
$1,870.56 |
| Rate for Payer: Aetna Commercial |
$1,500.34
|
| Rate for Payer: Anthem Medicaid |
$670.09
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.83
|
| Rate for Payer: Cash Price |
$974.25
|
| Rate for Payer: Cigna Commercial |
$1,617.26
|
| Rate for Payer: First Health Commercial |
$1,851.08
|
| Rate for Payer: Humana Commercial |
$1,656.22
|
| Rate for Payer: Humana KY Medicaid |
$670.09
|
| Rate for Payer: Kentucky WC Medicaid |
$676.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.55
|
| Rate for Payer: Molina Healthcare Medicaid |
$683.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$604.04
|
| Rate for Payer: PHCS Commercial |
$1,870.56
|
| Rate for Payer: United Healthcare All Payer |
$1,714.68
|
|
|
GOLDWIRE 300CM
|
Facility
|
IP
|
$1,948.50
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$253.30 |
| Max. Negotiated Rate |
$1,870.56 |
| Rate for Payer: Aetna Commercial |
$1,500.34
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,519.83
|
| Rate for Payer: Cash Price |
$974.25
|
| Rate for Payer: Cigna Commercial |
$1,617.26
|
| Rate for Payer: First Health Commercial |
$1,851.08
|
| Rate for Payer: Humana Commercial |
$1,656.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,597.77
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,437.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,714.68
|
| Rate for Payer: Ohio Health Group HMO |
$1,461.38
|
| Rate for Payer: Ohio Health Group PPO Differential |
$389.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$253.30
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$604.04
|
| Rate for Payer: PHCS Commercial |
$1,870.56
|
| Rate for Payer: United Healthcare All Payer |
$1,714.68
|
|
|
GOLF EVALUATION
|
Facility
|
IP
|
$113.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
42000036
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.03
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
GOLF EVALUATION
|
Facility
|
OP
|
$113.00
|
|
|
Service Code
|
HCPCS 97750
|
| Hospital Charge Code |
42000036
|
|
Hospital Revenue Code
|
429
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$108.48 |
| Rate for Payer: Aetna Commercial |
$87.01
|
| Rate for Payer: Anthem Medicaid |
$38.86
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$88.14
|
| Rate for Payer: Cash Price |
$56.50
|
| Rate for Payer: Cigna Commercial |
$93.79
|
| Rate for Payer: First Health Commercial |
$107.35
|
| Rate for Payer: Humana Commercial |
$96.05
|
| Rate for Payer: Humana KY Medicaid |
$38.86
|
| Rate for Payer: Kentucky WC Medicaid |
$39.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$92.66
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$83.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$33.90
|
| Rate for Payer: Molina Healthcare Medicaid |
$39.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$99.44
|
| Rate for Payer: Ohio Health Group HMO |
$84.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$22.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$14.69
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$35.03
|
| Rate for Payer: PHCS Commercial |
$108.48
|
| Rate for Payer: United Healthcare All Payer |
$99.44
|
|
|
GOLYTELY SOLUTION (TF) 4000ML
|
Facility
|
OP
|
$4.22
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
25000736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem Medicaid |
$1.45
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Humana KY Medicaid |
$1.45
|
| Rate for Payer: Kentucky WC Medicaid |
$1.47
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
|
GOLYTELY SOLUTION (TF) 4000ML
|
Facility
|
IP
|
$4.22
|
|
|
Service Code
|
NDC 52268010001
|
| Hospital Charge Code |
25000736
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$4.05 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.29
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cigna Commercial |
$3.50
|
| Rate for Payer: First Health Commercial |
$4.01
|
| Rate for Payer: Humana Commercial |
$3.59
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.46
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.11
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.71
|
| Rate for Payer: Ohio Health Group HMO |
$3.16
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.31
|
| Rate for Payer: PHCS Commercial |
$4.05
|
| Rate for Payer: United Healthcare All Payer |
$3.71
|
|
