|
G II DISHED INS SZ 3-4 15MM
|
Facility
|
IP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 3-4 18MM
|
Facility
|
IP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 3-4 18MM
|
Facility
|
OP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem Medicaid |
$1,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Humana KY Medicaid |
$1,722.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,739.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,756.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 3-4 21MM
|
Facility
|
IP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 3-4 21MM
|
Facility
|
OP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem Medicaid |
$1,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Humana KY Medicaid |
$1,722.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,739.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,756.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 3-4 9MM
|
Facility
|
OP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem Medicaid |
$1,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Humana KY Medicaid |
$1,722.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,739.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,756.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 3-4 9MM
|
Facility
|
IP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 5-6 11MM
|
Facility
|
IP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 5-6 11MM
|
Facility
|
OP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem Medicaid |
$1,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Humana KY Medicaid |
$1,722.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,739.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,756.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 5-6 9MM
|
Facility
|
OP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem Medicaid |
$1,722.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Humana KY Medicaid |
$1,722.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,739.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,756.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
G II DISHED INS SZ 5-6 9MM
|
Facility
|
IP
|
$5,007.50
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,502.25 |
| Max. Negotiated Rate |
$4,807.20 |
| Rate for Payer: Aetna Commercial |
$3,855.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,905.85
|
| Rate for Payer: Cash Price |
$2,503.75
|
| Rate for Payer: Cigna Commercial |
$4,156.23
|
| Rate for Payer: First Health Commercial |
$4,757.12
|
| Rate for Payer: Humana Commercial |
$4,256.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4,106.15
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,695.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,502.25
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,406.60
|
| Rate for Payer: Ohio Health Group HMO |
$3,755.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,006.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,356.52
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,455.18
|
| Rate for Payer: PHCS Commercial |
$4,807.20
|
| Rate for Payer: United Healthcare All Payer |
$4,406.60
|
|
|
GII HA POR TIBIAL SZ 2 LT
|
Facility
|
OP
|
$9,451.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,835.41 |
| Max. Negotiated Rate |
$9,073.32 |
| Rate for Payer: Aetna Commercial |
$7,277.56
|
| Rate for Payer: Anthem Medicaid |
$3,250.33
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,372.08
|
| Rate for Payer: Cash Price |
$4,725.69
|
| Rate for Payer: Cigna Commercial |
$7,844.65
|
| Rate for Payer: First Health Commercial |
$8,978.81
|
| Rate for Payer: Humana Commercial |
$8,033.67
|
| Rate for Payer: Humana KY Medicaid |
$3,250.33
|
| Rate for Payer: Kentucky WC Medicaid |
$3,283.41
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,750.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,975.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,835.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,315.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,317.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,088.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,561.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,222.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,521.45
|
| Rate for Payer: PHCS Commercial |
$9,073.32
|
| Rate for Payer: United Healthcare All Payer |
$8,317.21
|
|
|
GII HA POR TIBIAL SZ 2 LT
|
Facility
|
IP
|
$9,451.38
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,835.41 |
| Max. Negotiated Rate |
$9,073.32 |
| Rate for Payer: Aetna Commercial |
$7,277.56
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,372.08
|
| Rate for Payer: Cash Price |
$4,725.69
|
| Rate for Payer: Cigna Commercial |
$7,844.65
|
| Rate for Payer: First Health Commercial |
$8,978.81
|
| Rate for Payer: Humana Commercial |
$8,033.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,750.13
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,975.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,835.41
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,317.21
|
| Rate for Payer: Ohio Health Group HMO |
$7,088.53
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7,561.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8,222.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,521.45
|
| Rate for Payer: PHCS Commercial |
$9,073.32
|
| Rate for Payer: United Healthcare All Payer |
$8,317.21
|
|
|
GII HA POR TIBIAL SZ 2 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII HA POR TIBIAL SZ 2 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII HA POR TIBIAL SZ 3 LT
|
Facility
|
IP
|
$8,745.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,623.53 |
| Max. Negotiated Rate |
$8,395.30 |
| Rate for Payer: Aetna Commercial |
$6,733.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,821.18
|
| Rate for Payer: Cash Price |
$4,372.55
|
| Rate for Payer: Cigna Commercial |
$7,258.43
|
| Rate for Payer: First Health Commercial |
$8,307.84
|
| Rate for Payer: Humana Commercial |
$7,433.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,170.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,453.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,623.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,695.69
|
| Rate for Payer: Ohio Health Group HMO |
$6,558.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,996.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,608.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,034.12
|
| Rate for Payer: PHCS Commercial |
$8,395.30
|
| Rate for Payer: United Healthcare All Payer |
$7,695.69
|
|
|
GII HA POR TIBIAL SZ 3 LT
|
Facility
|
OP
|
$8,745.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,623.53 |
| Max. Negotiated Rate |
$8,395.30 |
| Rate for Payer: Aetna Commercial |
$6,733.73
|
| Rate for Payer: Anthem Medicaid |
$3,007.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,821.18
|
| Rate for Payer: Cash Price |
$4,372.55
|
| Rate for Payer: Cigna Commercial |
$7,258.43
|
| Rate for Payer: First Health Commercial |
$8,307.84
|
| Rate for Payer: Humana Commercial |
$7,433.34
|
| Rate for Payer: Humana KY Medicaid |
$3,007.44
|
| Rate for Payer: Kentucky WC Medicaid |
$3,038.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,170.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,453.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,623.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,067.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,695.69
|
| Rate for Payer: Ohio Health Group HMO |
$6,558.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,996.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,608.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,034.12
|
| Rate for Payer: PHCS Commercial |
$8,395.30
|
| Rate for Payer: United Healthcare All Payer |
$7,695.69
|
|
|
GII HA POR TIBIAL SZ 3 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII HA POR TIBIAL SZ 3 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII HA POR TIBIAL SZ 4 LT
|
Facility
|
IP
|
$8,745.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,623.53 |
| Max. Negotiated Rate |
$8,395.30 |
| Rate for Payer: Aetna Commercial |
$6,733.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,821.18
|
| Rate for Payer: Cash Price |
$4,372.55
|
| Rate for Payer: Cigna Commercial |
$7,258.43
|
| Rate for Payer: First Health Commercial |
$8,307.84
|
| Rate for Payer: Humana Commercial |
$7,433.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,170.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,453.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,623.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,695.69
|
| Rate for Payer: Ohio Health Group HMO |
$6,558.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,996.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,608.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,034.12
|
| Rate for Payer: PHCS Commercial |
$8,395.30
|
| Rate for Payer: United Healthcare All Payer |
$7,695.69
|
|
|
GII HA POR TIBIAL SZ 4 LT
|
Facility
|
OP
|
$8,745.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,623.53 |
| Max. Negotiated Rate |
$8,395.30 |
| Rate for Payer: Aetna Commercial |
$6,733.73
|
| Rate for Payer: Anthem Medicaid |
$3,007.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,821.18
|
| Rate for Payer: Cash Price |
$4,372.55
|
| Rate for Payer: Cigna Commercial |
$7,258.43
|
| Rate for Payer: First Health Commercial |
$8,307.84
|
| Rate for Payer: Humana Commercial |
$7,433.34
|
| Rate for Payer: Humana KY Medicaid |
$3,007.44
|
| Rate for Payer: Kentucky WC Medicaid |
$3,038.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,170.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,453.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,623.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,067.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,695.69
|
| Rate for Payer: Ohio Health Group HMO |
$6,558.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,996.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,608.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,034.12
|
| Rate for Payer: PHCS Commercial |
$8,395.30
|
| Rate for Payer: United Healthcare All Payer |
$7,695.69
|
|
|
GII HA POR TIBIAL SZ 4 RT
|
Facility
|
IP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII HA POR TIBIAL SZ 4 RT
|
Facility
|
OP
|
$12,785.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,835.53 |
| Max. Negotiated Rate |
$12,273.70 |
| Rate for Payer: Aetna Commercial |
$9,844.53
|
| Rate for Payer: Anthem Medicaid |
$4,396.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,972.38
|
| Rate for Payer: Cash Price |
$6,392.55
|
| Rate for Payer: Cigna Commercial |
$10,611.63
|
| Rate for Payer: First Health Commercial |
$12,145.84
|
| Rate for Payer: Humana Commercial |
$10,867.33
|
| Rate for Payer: Humana KY Medicaid |
$4,396.80
|
| Rate for Payer: Kentucky WC Medicaid |
$4,441.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,483.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,435.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,835.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,485.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,250.89
|
| Rate for Payer: Ohio Health Group HMO |
$9,588.83
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,228.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$11,123.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,821.72
|
| Rate for Payer: PHCS Commercial |
$12,273.70
|
| Rate for Payer: United Healthcare All Payer |
$11,250.89
|
|
|
GII HA POR TIBIAL SZ 5 LT
|
Facility
|
IP
|
$8,745.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,623.53 |
| Max. Negotiated Rate |
$8,395.30 |
| Rate for Payer: Aetna Commercial |
$6,733.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,821.18
|
| Rate for Payer: Cash Price |
$4,372.55
|
| Rate for Payer: Cigna Commercial |
$7,258.43
|
| Rate for Payer: First Health Commercial |
$8,307.84
|
| Rate for Payer: Humana Commercial |
$7,433.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,170.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,453.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,623.53
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,695.69
|
| Rate for Payer: Ohio Health Group HMO |
$6,558.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,996.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,608.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,034.12
|
| Rate for Payer: PHCS Commercial |
$8,395.30
|
| Rate for Payer: United Healthcare All Payer |
$7,695.69
|
|
|
GII HA POR TIBIAL SZ 5 LT
|
Facility
|
OP
|
$8,745.10
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,623.53 |
| Max. Negotiated Rate |
$8,395.30 |
| Rate for Payer: Aetna Commercial |
$6,733.73
|
| Rate for Payer: Anthem Medicaid |
$3,007.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,821.18
|
| Rate for Payer: Cash Price |
$4,372.55
|
| Rate for Payer: Cigna Commercial |
$7,258.43
|
| Rate for Payer: First Health Commercial |
$8,307.84
|
| Rate for Payer: Humana Commercial |
$7,433.34
|
| Rate for Payer: Humana KY Medicaid |
$3,007.44
|
| Rate for Payer: Kentucky WC Medicaid |
$3,038.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,170.98
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,453.88
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,623.53
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,067.78
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,695.69
|
| Rate for Payer: Ohio Health Group HMO |
$6,558.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,996.08
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,608.24
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6,034.12
|
| Rate for Payer: PHCS Commercial |
$8,395.30
|
| Rate for Payer: United Healthcare All Payer |
$7,695.69
|
|
