|
GNS II POR TIB SZ 6 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 6 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 7 LEFT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 7 LEFT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 7 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 7 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 8 LEFT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 8 LEFT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 8 RIGHT
|
Facility
|
IP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II POR TIB SZ 8 RIGHT
|
Facility
|
OP
|
$8,433.02
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,529.91 |
| Max. Negotiated Rate |
$8,095.70 |
| Rate for Payer: Aetna Commercial |
$6,493.43
|
| Rate for Payer: Anthem Medicaid |
$2,900.12
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,577.76
|
| Rate for Payer: Cash Price |
$4,216.51
|
| Rate for Payer: Cigna Commercial |
$6,999.41
|
| Rate for Payer: First Health Commercial |
$8,011.37
|
| Rate for Payer: Humana Commercial |
$7,168.07
|
| Rate for Payer: Humana KY Medicaid |
$2,900.12
|
| Rate for Payer: Kentucky WC Medicaid |
$2,929.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,915.08
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,223.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,529.91
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,958.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,421.06
|
| Rate for Payer: Ohio Health Group HMO |
$6,324.77
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,746.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,336.73
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,818.78
|
| Rate for Payer: PHCS Commercial |
$8,095.70
|
| Rate for Payer: United Healthcare All Payer |
$7,421.06
|
|
|
GNS II RESURF PAT 26MM
|
Facility
|
OP
|
$4,669.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,400.72 |
| Max. Negotiated Rate |
$4,482.30 |
| Rate for Payer: Aetna Commercial |
$3,595.18
|
| Rate for Payer: Anthem Medicaid |
$1,605.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,641.87
|
| Rate for Payer: Cash Price |
$2,334.53
|
| Rate for Payer: Cigna Commercial |
$3,875.32
|
| Rate for Payer: First Health Commercial |
$4,435.61
|
| Rate for Payer: Humana Commercial |
$3,968.70
|
| Rate for Payer: Humana KY Medicaid |
$1,605.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1,622.03
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,828.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,445.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,400.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,637.91
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,108.77
|
| Rate for Payer: Ohio Health Group HMO |
$3,501.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,735.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,062.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,221.65
|
| Rate for Payer: PHCS Commercial |
$4,482.30
|
| Rate for Payer: United Healthcare All Payer |
$4,108.77
|
|
|
GNS II RESURF PAT 26MM
|
Facility
|
IP
|
$4,669.06
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,400.72 |
| Max. Negotiated Rate |
$4,482.30 |
| Rate for Payer: Aetna Commercial |
$3,595.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,641.87
|
| Rate for Payer: Cash Price |
$2,334.53
|
| Rate for Payer: Cigna Commercial |
$3,875.32
|
| Rate for Payer: First Health Commercial |
$4,435.61
|
| Rate for Payer: Humana Commercial |
$3,968.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,828.63
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,445.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,400.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,108.77
|
| Rate for Payer: Ohio Health Group HMO |
$3,501.80
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,735.25
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,062.08
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,221.65
|
| Rate for Payer: PHCS Commercial |
$4,482.30
|
| Rate for Payer: United Healthcare All Payer |
$4,108.77
|
|
|
GOLDENBERG CAP PROSTHESIS 1.5L
|
Facility
|
IP
|
$3,364.59
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,009.38 |
| Max. Negotiated Rate |
$3,230.01 |
| Rate for Payer: Aetna Commercial |
$2,590.73
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,624.38
|
| Rate for Payer: Cash Price |
$1,682.29
|
| Rate for Payer: Cigna Commercial |
$2,792.61
|
| Rate for Payer: First Health Commercial |
$3,196.36
|
| Rate for Payer: Humana Commercial |
$2,859.90
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,758.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,483.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,009.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,960.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,523.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,691.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,927.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,321.57
|
| Rate for Payer: PHCS Commercial |
$3,230.01
|
| Rate for Payer: United Healthcare All Payer |
$2,960.84
|
|
|
GOLDENBERG CAP PROSTHESIS 1.5L
|
Facility
|
OP
|
$3,364.59
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,009.38 |
| Max. Negotiated Rate |
$3,230.01 |
| Rate for Payer: Aetna Commercial |
$2,590.73
|
| Rate for Payer: Anthem Medicaid |
$1,157.08
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,624.38
|
| Rate for Payer: Cash Price |
$1,682.29
|
| Rate for Payer: Cigna Commercial |
$2,792.61
|
| Rate for Payer: First Health Commercial |
$3,196.36
|
| Rate for Payer: Humana Commercial |
$2,859.90
|
| Rate for Payer: Humana KY Medicaid |
$1,157.08
|
| Rate for Payer: Kentucky WC Medicaid |
$1,168.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,758.96
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,483.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,009.38
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,180.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,960.84
|
| Rate for Payer: Ohio Health Group HMO |
$2,523.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,691.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,927.19
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,321.57
|
| Rate for Payer: PHCS Commercial |
$3,230.01
|
| Rate for Payer: United Healthcare All Payer |
$2,960.84
|
|
|
GOLDENBERG INCUS PROST 4.2 L
|
Facility
|
IP
|
$3,515.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,054.72 |
| Max. Negotiated Rate |
$3,375.12 |
| Rate for Payer: Aetna Commercial |
$2,707.13
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,742.28
|
| Rate for Payer: Cash Price |
$1,757.88
|
| Rate for Payer: Cigna Commercial |
$2,918.07
|
| Rate for Payer: First Health Commercial |
$3,339.96
|
| Rate for Payer: Humana Commercial |
$2,988.39
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,882.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,594.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,054.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,093.86
|
| Rate for Payer: Ohio Health Group HMO |
$2,636.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,812.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,058.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,425.87
|
| Rate for Payer: PHCS Commercial |
$3,375.12
|
| Rate for Payer: United Healthcare All Payer |
$3,093.86
|
|
|
GOLDENBERG INCUS PROST 4.2 L
|
Facility
|
OP
|
$3,515.75
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,054.72 |
| Max. Negotiated Rate |
$3,375.12 |
| Rate for Payer: Aetna Commercial |
$2,707.13
|
| Rate for Payer: Anthem Medicaid |
$1,209.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,742.28
|
| Rate for Payer: Cash Price |
$1,757.88
|
| Rate for Payer: Cigna Commercial |
$2,918.07
|
| Rate for Payer: First Health Commercial |
$3,339.96
|
| Rate for Payer: Humana Commercial |
$2,988.39
|
| Rate for Payer: Humana KY Medicaid |
$1,209.07
|
| Rate for Payer: Kentucky WC Medicaid |
$1,221.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,882.91
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,594.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,054.72
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,233.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,093.86
|
| Rate for Payer: Ohio Health Group HMO |
$2,636.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,812.60
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,058.70
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,425.87
|
| Rate for Payer: PHCS Commercial |
$3,375.12
|
| Rate for Payer: United Healthcare All Payer |
$3,093.86
|
|
|
GOLDENBERG INCUS PROST 8.2 L
|
Facility
|
IP
|
$3,419.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,025.97 |
| Max. Negotiated Rate |
$3,283.10 |
| Rate for Payer: Aetna Commercial |
$2,633.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,667.52
|
| Rate for Payer: Cash Price |
$1,709.95
|
| Rate for Payer: Cigna Commercial |
$2,838.52
|
| Rate for Payer: First Health Commercial |
$3,248.91
|
| Rate for Payer: Humana Commercial |
$2,906.91
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,804.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,523.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,025.97
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,009.51
|
| Rate for Payer: Ohio Health Group HMO |
$2,564.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,735.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,975.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,359.73
|
| Rate for Payer: PHCS Commercial |
$3,283.10
|
| Rate for Payer: United Healthcare All Payer |
$3,009.51
|
|
|
GOLDENBERG INCUS PROST 8.2 L
|
Facility
|
OP
|
$3,419.90
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,025.97 |
| Max. Negotiated Rate |
$3,283.10 |
| Rate for Payer: Aetna Commercial |
$2,633.32
|
| Rate for Payer: Anthem Medicaid |
$1,176.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,667.52
|
| Rate for Payer: Cash Price |
$1,709.95
|
| Rate for Payer: Cigna Commercial |
$2,838.52
|
| Rate for Payer: First Health Commercial |
$3,248.91
|
| Rate for Payer: Humana Commercial |
$2,906.91
|
| Rate for Payer: Humana KY Medicaid |
$1,176.10
|
| Rate for Payer: Kentucky WC Medicaid |
$1,188.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,804.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,523.89
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,025.97
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,199.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,009.51
|
| Rate for Payer: Ohio Health Group HMO |
$2,564.93
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,735.92
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,975.31
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,359.73
|
| Rate for Payer: PHCS Commercial |
$3,283.10
|
| Rate for Payer: United Healthcare All Payer |
$3,009.51
|
|
|
GOLDENBERG MALLEABLE PORP 5.1L
|
Facility
|
IP
|
$3,530.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,059.07 |
| Max. Negotiated Rate |
$3,389.01 |
| Rate for Payer: Aetna Commercial |
$2,718.27
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.57
|
| Rate for Payer: Cash Price |
$1,765.11
|
| Rate for Payer: Cigna Commercial |
$2,930.08
|
| Rate for Payer: First Health Commercial |
$3,353.71
|
| Rate for Payer: Humana Commercial |
$3,000.69
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.07
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,824.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,071.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,435.85
|
| Rate for Payer: PHCS Commercial |
$3,389.01
|
| Rate for Payer: United Healthcare All Payer |
$3,106.59
|
|
|
GOLDENBERG MALLEABLE PORP 5.1L
|
Facility
|
OP
|
$3,530.22
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,059.07 |
| Max. Negotiated Rate |
$3,389.01 |
| Rate for Payer: Aetna Commercial |
$2,718.27
|
| Rate for Payer: Anthem Medicaid |
$1,214.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,753.57
|
| Rate for Payer: Cash Price |
$1,765.11
|
| Rate for Payer: Cigna Commercial |
$2,930.08
|
| Rate for Payer: First Health Commercial |
$3,353.71
|
| Rate for Payer: Humana Commercial |
$3,000.69
|
| Rate for Payer: Humana KY Medicaid |
$1,214.04
|
| Rate for Payer: Kentucky WC Medicaid |
$1,226.40
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,894.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,605.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,059.07
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,238.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,106.59
|
| Rate for Payer: Ohio Health Group HMO |
$2,647.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,824.18
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,071.29
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,435.85
|
| Rate for Payer: PHCS Commercial |
$3,389.01
|
| Rate for Payer: United Healthcare All Payer |
$3,106.59
|
|
|
GOLDENBERG PORP PROST 5.5 L
|
Facility
|
IP
|
$3,572.49
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,071.75 |
| Max. Negotiated Rate |
$3,429.59 |
| Rate for Payer: Aetna Commercial |
$2,750.82
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,786.54
|
| Rate for Payer: Cash Price |
$1,786.24
|
| Rate for Payer: Cigna Commercial |
$2,965.17
|
| Rate for Payer: First Health Commercial |
$3,393.87
|
| Rate for Payer: Humana Commercial |
$3,036.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,929.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,071.75
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,143.79
|
| Rate for Payer: Ohio Health Group HMO |
$2,679.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,857.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,108.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,465.02
|
| Rate for Payer: PHCS Commercial |
$3,429.59
|
| Rate for Payer: United Healthcare All Payer |
$3,143.79
|
|
|
GOLDENBERG PORP PROST 5.5 L
|
Facility
|
OP
|
$3,572.49
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,071.75 |
| Max. Negotiated Rate |
$3,429.59 |
| Rate for Payer: Aetna Commercial |
$2,750.82
|
| Rate for Payer: Anthem Medicaid |
$1,228.58
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,786.54
|
| Rate for Payer: Cash Price |
$1,786.24
|
| Rate for Payer: Cigna Commercial |
$2,965.17
|
| Rate for Payer: First Health Commercial |
$3,393.87
|
| Rate for Payer: Humana Commercial |
$3,036.62
|
| Rate for Payer: Humana KY Medicaid |
$1,228.58
|
| Rate for Payer: Kentucky WC Medicaid |
$1,241.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,929.44
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,636.50
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,071.75
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,253.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,143.79
|
| Rate for Payer: Ohio Health Group HMO |
$2,679.37
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,857.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,108.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,465.02
|
| Rate for Payer: PHCS Commercial |
$3,429.59
|
| Rate for Payer: United Healthcare All Payer |
$3,143.79
|
|
|
GOLDENBERG TORP PROST 8.0 L
|
Facility
|
OP
|
$3,550.51
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,065.15 |
| Max. Negotiated Rate |
$3,408.49 |
| Rate for Payer: Aetna Commercial |
$2,733.89
|
| Rate for Payer: Anthem Medicaid |
$1,221.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.40
|
| Rate for Payer: Cash Price |
$1,775.26
|
| Rate for Payer: Cigna Commercial |
$2,946.92
|
| Rate for Payer: First Health Commercial |
$3,372.98
|
| Rate for Payer: Humana Commercial |
$3,017.93
|
| Rate for Payer: Humana KY Medicaid |
$1,221.02
|
| Rate for Payer: Kentucky WC Medicaid |
$1,233.45
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,620.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.15
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,245.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,662.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,840.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,088.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,449.85
|
| Rate for Payer: PHCS Commercial |
$3,408.49
|
| Rate for Payer: United Healthcare All Payer |
$3,124.45
|
|
|
GOLDENBERG TORP PROST 8.0 L
|
Facility
|
IP
|
$3,550.51
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,065.15 |
| Max. Negotiated Rate |
$3,408.49 |
| Rate for Payer: Aetna Commercial |
$2,733.89
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,769.40
|
| Rate for Payer: Cash Price |
$1,775.26
|
| Rate for Payer: Cigna Commercial |
$2,946.92
|
| Rate for Payer: First Health Commercial |
$3,372.98
|
| Rate for Payer: Humana Commercial |
$3,017.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,911.42
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,620.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,065.15
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,124.45
|
| Rate for Payer: Ohio Health Group HMO |
$2,662.88
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,840.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,088.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,449.85
|
| Rate for Payer: PHCS Commercial |
$3,408.49
|
| Rate for Payer: United Healthcare All Payer |
$3,124.45
|
|
|
GOLDWIRE 300CM
|
Facility
|
IP
|
$1,949.80
|
|
|
Service Code
|
HCPCS C1769
|
| Hospital Charge Code |
27000056
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$584.94 |
| Max. Negotiated Rate |
$1,871.81 |
| Rate for Payer: Aetna Commercial |
$1,501.35
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,520.84
|
| Rate for Payer: Cash Price |
$974.90
|
| Rate for Payer: Cigna Commercial |
$1,618.33
|
| Rate for Payer: First Health Commercial |
$1,852.31
|
| Rate for Payer: Humana Commercial |
$1,657.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,598.84
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,438.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$584.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,715.82
|
| Rate for Payer: Ohio Health Group HMO |
$1,462.35
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,559.84
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,696.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,345.36
|
| Rate for Payer: PHCS Commercial |
$1,871.81
|
| Rate for Payer: United Healthcare All Payer |
$1,715.82
|
|
