|
OMNICEF (CEFDINIR) 300MG CAP
|
Facility
|
OP
|
$9.21
|
|
|
Service Code
|
NDC 68001036206
|
| Hospital Charge Code |
25003312
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.76 |
| Max. Negotiated Rate |
$8.84 |
| Rate for Payer: Aetna Commercial |
$7.09
|
| Rate for Payer: Anthem Medicaid |
$3.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.18
|
| Rate for Payer: Cash Price |
$4.61
|
| Rate for Payer: Cigna Commercial |
$7.64
|
| Rate for Payer: First Health Commercial |
$8.75
|
| Rate for Payer: Humana Commercial |
$7.83
|
| Rate for Payer: Humana KY Medicaid |
$3.17
|
| Rate for Payer: Kentucky WC Medicaid |
$3.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.80
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.76
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.23
|
| Rate for Payer: Ohio Health Choice Commercial |
$8.10
|
| Rate for Payer: Ohio Health Group HMO |
$6.91
|
| Rate for Payer: Ohio Health Group PPO Differential |
$7.37
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$8.01
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.35
|
| Rate for Payer: PHCS Commercial |
$8.84
|
| Rate for Payer: United Healthcare All Payer |
$8.10
|
|
|
OMNIFIT CEMENT SPACERS 10MM
|
Facility
|
OP
|
$1,885.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$565.56 |
| Max. Negotiated Rate |
$1,809.79 |
| Rate for Payer: Aetna Commercial |
$1,451.60
|
| Rate for Payer: Anthem Medicaid |
$648.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,470.46
|
| Rate for Payer: Cash Price |
$942.60
|
| Rate for Payer: Cigna Commercial |
$1,564.72
|
| Rate for Payer: First Health Commercial |
$1,790.94
|
| Rate for Payer: Humana Commercial |
$1,602.42
|
| Rate for Payer: Humana KY Medicaid |
$648.32
|
| Rate for Payer: Kentucky WC Medicaid |
$654.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,545.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,391.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$565.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$661.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,658.98
|
| Rate for Payer: Ohio Health Group HMO |
$1,413.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,640.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,300.79
|
| Rate for Payer: PHCS Commercial |
$1,809.79
|
| Rate for Payer: United Healthcare All Payer |
$1,658.98
|
|
|
OMNIFIT CEMENT SPACERS 10MM
|
Facility
|
IP
|
$1,885.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$565.56 |
| Max. Negotiated Rate |
$1,809.79 |
| Rate for Payer: Aetna Commercial |
$1,451.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,470.46
|
| Rate for Payer: Cash Price |
$942.60
|
| Rate for Payer: Cigna Commercial |
$1,564.72
|
| Rate for Payer: First Health Commercial |
$1,790.94
|
| Rate for Payer: Humana Commercial |
$1,602.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,545.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,391.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$565.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,658.98
|
| Rate for Payer: Ohio Health Group HMO |
$1,413.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,640.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,300.79
|
| Rate for Payer: PHCS Commercial |
$1,809.79
|
| Rate for Payer: United Healthcare All Payer |
$1,658.98
|
|
|
OMNIFIT CEMENT SPACERS 11M
|
Facility
|
OP
|
$1,863.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.18 |
| Max. Negotiated Rate |
$1,789.36 |
| Rate for Payer: Aetna Commercial |
$1,435.22
|
| Rate for Payer: Anthem Medicaid |
$641.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,453.86
|
| Rate for Payer: Cash Price |
$931.96
|
| Rate for Payer: Cigna Commercial |
$1,547.05
|
| Rate for Payer: First Health Commercial |
$1,770.72
|
| Rate for Payer: Humana Commercial |
$1,584.33
|
| Rate for Payer: Humana KY Medicaid |
$641.00
|
| Rate for Payer: Kentucky WC Medicaid |
$647.53
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,528.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,375.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.18
|
| Rate for Payer: Molina Healthcare Medicaid |
$653.86
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,640.25
|
| Rate for Payer: Ohio Health Group HMO |
$1,397.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,491.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,621.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,286.10
|
| Rate for Payer: PHCS Commercial |
$1,789.36
|
| Rate for Payer: United Healthcare All Payer |
$1,640.25
|
|
|
OMNIFIT CEMENT SPACERS 11M
|
Facility
|
IP
|
$1,863.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$559.18 |
| Max. Negotiated Rate |
$1,789.36 |
| Rate for Payer: Aetna Commercial |
$1,435.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,453.86
|
| Rate for Payer: Cash Price |
$931.96
|
| Rate for Payer: Cigna Commercial |
$1,547.05
|
| Rate for Payer: First Health Commercial |
$1,770.72
|
| Rate for Payer: Humana Commercial |
$1,584.33
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,528.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,375.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$559.18
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,640.25
|
| Rate for Payer: Ohio Health Group HMO |
$1,397.94
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,491.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,621.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,286.10
|
| Rate for Payer: PHCS Commercial |
$1,789.36
|
| Rate for Payer: United Healthcare All Payer |
$1,640.25
|
|
|
OMNIFIT CEMENT SPACERS 12MM
|
Facility
|
IP
|
$1,765.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.54 |
| Max. Negotiated Rate |
$1,694.52 |
| Rate for Payer: Aetna Commercial |
$1,359.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.79
|
| Rate for Payer: Cash Price |
$882.56
|
| Rate for Payer: Cigna Commercial |
$1,465.05
|
| Rate for Payer: First Health Commercial |
$1,676.86
|
| Rate for Payer: Humana Commercial |
$1,500.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,447.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,553.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,535.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,217.93
|
| Rate for Payer: PHCS Commercial |
$1,694.52
|
| Rate for Payer: United Healthcare All Payer |
$1,553.31
|
|
|
OMNIFIT CEMENT SPACERS 12MM
|
Facility
|
OP
|
$1,765.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.54 |
| Max. Negotiated Rate |
$1,694.52 |
| Rate for Payer: Aetna Commercial |
$1,359.14
|
| Rate for Payer: Anthem Medicaid |
$607.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.79
|
| Rate for Payer: Cash Price |
$882.56
|
| Rate for Payer: Cigna Commercial |
$1,465.05
|
| Rate for Payer: First Health Commercial |
$1,676.86
|
| Rate for Payer: Humana Commercial |
$1,500.35
|
| Rate for Payer: Humana KY Medicaid |
$607.02
|
| Rate for Payer: Kentucky WC Medicaid |
$613.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,447.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$619.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,553.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,535.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,217.93
|
| Rate for Payer: PHCS Commercial |
$1,694.52
|
| Rate for Payer: United Healthcare All Payer |
$1,553.31
|
|
|
OMNIFIT CEMENT SPACERS 13MM
|
Facility
|
IP
|
$1,749.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.98 |
| Max. Negotiated Rate |
$1,679.92 |
| Rate for Payer: Aetna Commercial |
$1,347.44
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,364.94
|
| Rate for Payer: Cash Price |
$874.96
|
| Rate for Payer: Cigna Commercial |
$1,452.43
|
| Rate for Payer: First Health Commercial |
$1,662.42
|
| Rate for Payer: Humana Commercial |
$1,487.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,434.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$524.98
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,539.93
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,399.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.44
|
| Rate for Payer: PHCS Commercial |
$1,679.92
|
| Rate for Payer: United Healthcare All Payer |
$1,539.93
|
|
|
OMNIFIT CEMENT SPACERS 13MM
|
Facility
|
OP
|
$1,749.92
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.98 |
| Max. Negotiated Rate |
$1,679.92 |
| Rate for Payer: Aetna Commercial |
$1,347.44
|
| Rate for Payer: Anthem Medicaid |
$601.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,364.94
|
| Rate for Payer: Cash Price |
$874.96
|
| Rate for Payer: Cigna Commercial |
$1,452.43
|
| Rate for Payer: First Health Commercial |
$1,662.42
|
| Rate for Payer: Humana Commercial |
$1,487.43
|
| Rate for Payer: Humana KY Medicaid |
$601.80
|
| Rate for Payer: Kentucky WC Medicaid |
$607.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,434.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,291.44
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$524.98
|
| Rate for Payer: Molina Healthcare Medicaid |
$613.87
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,539.93
|
| Rate for Payer: Ohio Health Group HMO |
$1,312.44
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,399.94
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,522.43
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,207.44
|
| Rate for Payer: PHCS Commercial |
$1,679.92
|
| Rate for Payer: United Healthcare All Payer |
$1,539.93
|
|
|
OMNIFIT CEMENT SPACERS 14MM
|
Facility
|
IP
|
$1,765.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.54 |
| Max. Negotiated Rate |
$1,694.52 |
| Rate for Payer: Aetna Commercial |
$1,359.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.79
|
| Rate for Payer: Cash Price |
$882.56
|
| Rate for Payer: Cigna Commercial |
$1,465.05
|
| Rate for Payer: First Health Commercial |
$1,676.86
|
| Rate for Payer: Humana Commercial |
$1,500.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,447.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,553.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,535.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,217.93
|
| Rate for Payer: PHCS Commercial |
$1,694.52
|
| Rate for Payer: United Healthcare All Payer |
$1,553.31
|
|
|
OMNIFIT CEMENT SPACERS 14MM
|
Facility
|
OP
|
$1,765.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.54 |
| Max. Negotiated Rate |
$1,694.52 |
| Rate for Payer: Aetna Commercial |
$1,359.14
|
| Rate for Payer: Anthem Medicaid |
$607.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.79
|
| Rate for Payer: Cash Price |
$882.56
|
| Rate for Payer: Cigna Commercial |
$1,465.05
|
| Rate for Payer: First Health Commercial |
$1,676.86
|
| Rate for Payer: Humana Commercial |
$1,500.35
|
| Rate for Payer: Humana KY Medicaid |
$607.02
|
| Rate for Payer: Kentucky WC Medicaid |
$613.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,447.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$619.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,553.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,535.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,217.93
|
| Rate for Payer: PHCS Commercial |
$1,694.52
|
| Rate for Payer: United Healthcare All Payer |
$1,553.31
|
|
|
OMNIFIT CEMENT SPACERS 15MM
|
Facility
|
IP
|
$1,765.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.54 |
| Max. Negotiated Rate |
$1,694.52 |
| Rate for Payer: Aetna Commercial |
$1,359.14
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.79
|
| Rate for Payer: Cash Price |
$882.56
|
| Rate for Payer: Cigna Commercial |
$1,465.05
|
| Rate for Payer: First Health Commercial |
$1,676.86
|
| Rate for Payer: Humana Commercial |
$1,500.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,447.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,553.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,535.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,217.93
|
| Rate for Payer: PHCS Commercial |
$1,694.52
|
| Rate for Payer: United Healthcare All Payer |
$1,553.31
|
|
|
OMNIFIT CEMENT SPACERS 15MM
|
Facility
|
OP
|
$1,765.12
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$529.54 |
| Max. Negotiated Rate |
$1,694.52 |
| Rate for Payer: Aetna Commercial |
$1,359.14
|
| Rate for Payer: Anthem Medicaid |
$607.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,376.79
|
| Rate for Payer: Cash Price |
$882.56
|
| Rate for Payer: Cigna Commercial |
$1,465.05
|
| Rate for Payer: First Health Commercial |
$1,676.86
|
| Rate for Payer: Humana Commercial |
$1,500.35
|
| Rate for Payer: Humana KY Medicaid |
$607.02
|
| Rate for Payer: Kentucky WC Medicaid |
$613.20
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,447.40
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,302.66
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$529.54
|
| Rate for Payer: Molina Healthcare Medicaid |
$619.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,553.31
|
| Rate for Payer: Ohio Health Group HMO |
$1,323.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,412.10
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,535.65
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,217.93
|
| Rate for Payer: PHCS Commercial |
$1,694.52
|
| Rate for Payer: United Healthcare All Payer |
$1,553.31
|
|
|
OMNIFIT CEMENT SPACERS 16MM
|
Facility
|
OP
|
$1,500.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.29 |
| Max. Negotiated Rate |
$1,440.92 |
| Rate for Payer: Aetna Commercial |
$1,155.74
|
| Rate for Payer: Anthem Medicaid |
$516.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.75
|
| Rate for Payer: Cash Price |
$750.48
|
| Rate for Payer: Cigna Commercial |
$1,245.80
|
| Rate for Payer: First Health Commercial |
$1,425.91
|
| Rate for Payer: Humana Commercial |
$1,275.82
|
| Rate for Payer: Humana KY Medicaid |
$516.18
|
| Rate for Payer: Kentucky WC Medicaid |
$521.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.66
|
| Rate for Payer: PHCS Commercial |
$1,440.92
|
| Rate for Payer: United Healthcare All Payer |
$1,320.84
|
|
|
OMNIFIT CEMENT SPACERS 16MM
|
Facility
|
IP
|
$1,500.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.29 |
| Max. Negotiated Rate |
$1,440.92 |
| Rate for Payer: Aetna Commercial |
$1,155.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.75
|
| Rate for Payer: Cash Price |
$750.48
|
| Rate for Payer: Cigna Commercial |
$1,245.80
|
| Rate for Payer: First Health Commercial |
$1,425.91
|
| Rate for Payer: Humana Commercial |
$1,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.66
|
| Rate for Payer: PHCS Commercial |
$1,440.92
|
| Rate for Payer: United Healthcare All Payer |
$1,320.84
|
|
|
OMNIFIT CEMENT SPACERS 17MM
|
Facility
|
IP
|
$1,500.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.29 |
| Max. Negotiated Rate |
$1,440.92 |
| Rate for Payer: Aetna Commercial |
$1,155.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.75
|
| Rate for Payer: Cash Price |
$750.48
|
| Rate for Payer: Cigna Commercial |
$1,245.80
|
| Rate for Payer: First Health Commercial |
$1,425.91
|
| Rate for Payer: Humana Commercial |
$1,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.66
|
| Rate for Payer: PHCS Commercial |
$1,440.92
|
| Rate for Payer: United Healthcare All Payer |
$1,320.84
|
|
|
OMNIFIT CEMENT SPACERS 17MM
|
Facility
|
OP
|
$1,500.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.29 |
| Max. Negotiated Rate |
$1,440.92 |
| Rate for Payer: Aetna Commercial |
$1,155.74
|
| Rate for Payer: Anthem Medicaid |
$516.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.75
|
| Rate for Payer: Cash Price |
$750.48
|
| Rate for Payer: Cigna Commercial |
$1,245.80
|
| Rate for Payer: First Health Commercial |
$1,425.91
|
| Rate for Payer: Humana Commercial |
$1,275.82
|
| Rate for Payer: Humana KY Medicaid |
$516.18
|
| Rate for Payer: Kentucky WC Medicaid |
$521.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.66
|
| Rate for Payer: PHCS Commercial |
$1,440.92
|
| Rate for Payer: United Healthcare All Payer |
$1,320.84
|
|
|
OMNIFIT CEMENT SPACERS 18MM
|
Facility
|
IP
|
$1,500.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.29 |
| Max. Negotiated Rate |
$1,440.92 |
| Rate for Payer: Aetna Commercial |
$1,155.74
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.75
|
| Rate for Payer: Cash Price |
$750.48
|
| Rate for Payer: Cigna Commercial |
$1,245.80
|
| Rate for Payer: First Health Commercial |
$1,425.91
|
| Rate for Payer: Humana Commercial |
$1,275.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.29
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.66
|
| Rate for Payer: PHCS Commercial |
$1,440.92
|
| Rate for Payer: United Healthcare All Payer |
$1,320.84
|
|
|
OMNIFIT CEMENT SPACERS 18MM
|
Facility
|
OP
|
$1,500.96
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$450.29 |
| Max. Negotiated Rate |
$1,440.92 |
| Rate for Payer: Aetna Commercial |
$1,155.74
|
| Rate for Payer: Anthem Medicaid |
$516.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,170.75
|
| Rate for Payer: Cash Price |
$750.48
|
| Rate for Payer: Cigna Commercial |
$1,245.80
|
| Rate for Payer: First Health Commercial |
$1,425.91
|
| Rate for Payer: Humana Commercial |
$1,275.82
|
| Rate for Payer: Humana KY Medicaid |
$516.18
|
| Rate for Payer: Kentucky WC Medicaid |
$521.43
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,230.79
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,107.71
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$450.29
|
| Rate for Payer: Molina Healthcare Medicaid |
$526.54
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,320.84
|
| Rate for Payer: Ohio Health Group HMO |
$1,125.72
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,200.77
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,305.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,035.66
|
| Rate for Payer: PHCS Commercial |
$1,440.92
|
| Rate for Payer: United Healthcare All Payer |
$1,320.84
|
|
|
OMNIFIT CEMENT SPACERS 8MM
|
Facility
|
IP
|
$1,885.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$565.56 |
| Max. Negotiated Rate |
$1,809.79 |
| Rate for Payer: Aetna Commercial |
$1,451.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,470.46
|
| Rate for Payer: Cash Price |
$942.60
|
| Rate for Payer: Cigna Commercial |
$1,564.72
|
| Rate for Payer: First Health Commercial |
$1,790.94
|
| Rate for Payer: Humana Commercial |
$1,602.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,545.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,391.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$565.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,658.98
|
| Rate for Payer: Ohio Health Group HMO |
$1,413.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,640.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,300.79
|
| Rate for Payer: PHCS Commercial |
$1,809.79
|
| Rate for Payer: United Healthcare All Payer |
$1,658.98
|
|
|
OMNIFIT CEMENT SPACERS 8MM
|
Facility
|
OP
|
$1,885.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$565.56 |
| Max. Negotiated Rate |
$1,809.79 |
| Rate for Payer: Aetna Commercial |
$1,451.60
|
| Rate for Payer: Anthem Medicaid |
$648.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,470.46
|
| Rate for Payer: Cash Price |
$942.60
|
| Rate for Payer: Cigna Commercial |
$1,564.72
|
| Rate for Payer: First Health Commercial |
$1,790.94
|
| Rate for Payer: Humana Commercial |
$1,602.42
|
| Rate for Payer: Humana KY Medicaid |
$648.32
|
| Rate for Payer: Kentucky WC Medicaid |
$654.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,545.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,391.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$565.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$661.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,658.98
|
| Rate for Payer: Ohio Health Group HMO |
$1,413.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,640.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,300.79
|
| Rate for Payer: PHCS Commercial |
$1,809.79
|
| Rate for Payer: United Healthcare All Payer |
$1,658.98
|
|
|
OMNIFIT CEMENT SPACERS 9MM
|
Facility
|
OP
|
$1,885.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$565.56 |
| Max. Negotiated Rate |
$1,809.79 |
| Rate for Payer: Aetna Commercial |
$1,451.60
|
| Rate for Payer: Anthem Medicaid |
$648.32
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,470.46
|
| Rate for Payer: Cash Price |
$942.60
|
| Rate for Payer: Cigna Commercial |
$1,564.72
|
| Rate for Payer: First Health Commercial |
$1,790.94
|
| Rate for Payer: Humana Commercial |
$1,602.42
|
| Rate for Payer: Humana KY Medicaid |
$648.32
|
| Rate for Payer: Kentucky WC Medicaid |
$654.92
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,545.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,391.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$565.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$661.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,658.98
|
| Rate for Payer: Ohio Health Group HMO |
$1,413.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,640.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,300.79
|
| Rate for Payer: PHCS Commercial |
$1,809.79
|
| Rate for Payer: United Healthcare All Payer |
$1,658.98
|
|
|
OMNIFIT CEMENT SPACERS 9MM
|
Facility
|
IP
|
$1,885.20
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$565.56 |
| Max. Negotiated Rate |
$1,809.79 |
| Rate for Payer: Aetna Commercial |
$1,451.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,470.46
|
| Rate for Payer: Cash Price |
$942.60
|
| Rate for Payer: Cigna Commercial |
$1,564.72
|
| Rate for Payer: First Health Commercial |
$1,790.94
|
| Rate for Payer: Humana Commercial |
$1,602.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,545.86
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,391.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$565.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,658.98
|
| Rate for Payer: Ohio Health Group HMO |
$1,413.90
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,508.16
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,640.12
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,300.79
|
| Rate for Payer: PHCS Commercial |
$1,809.79
|
| Rate for Payer: United Healthcare All Payer |
$1,658.98
|
|
|
OMNIFIT CMT HIP STEM 132^ 30*1
|
Facility
|
IP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
|
OMNIFIT CMT HIP STEM 132^ 30*1
|
Facility
|
OP
|
$12,638.30
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,791.49 |
| Max. Negotiated Rate |
$12,132.77 |
| Rate for Payer: Aetna Commercial |
$9,731.49
|
| Rate for Payer: Anthem Medicaid |
$4,346.31
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,857.87
|
| Rate for Payer: Cash Price |
$6,319.15
|
| Rate for Payer: Cigna Commercial |
$10,489.79
|
| Rate for Payer: First Health Commercial |
$12,006.39
|
| Rate for Payer: Humana Commercial |
$10,742.56
|
| Rate for Payer: Humana KY Medicaid |
$4,346.31
|
| Rate for Payer: Kentucky WC Medicaid |
$4,390.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,363.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,327.07
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,791.49
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,433.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$11,121.70
|
| Rate for Payer: Ohio Health Group HMO |
$9,478.73
|
| Rate for Payer: Ohio Health Group PPO Differential |
$10,110.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$10,995.32
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$8,720.43
|
| Rate for Payer: PHCS Commercial |
$12,132.77
|
| Rate for Payer: United Healthcare All Payer |
$11,121.70
|
|
